L3 Vertebral Level Research Articles

Wireless high-frequency dorsal root ganglion stimulation for chronic low back pain: A pilot study.

Evaluation of the efficacy of a wireless high-frequency stimulator placed over selected DRG of exiting nerve roots for the treatment of chronic low back pain. Feasibility. Six subjects with chronic, intractable back pain refractory to standard medical treatment. Four stimulators (Freedom-4A) provided by Stimwave Technologies, were implanted over the DRG exiting nerve roots, bilaterally at both the T9 and L2 vertebral levels. Subjects were asked to evaluate stimulation independently with the devices turned on at T9 and subsequently L2 for each of 2weeks. Subjects were then monitored for 8weeks with the preferred stimulator. Pain reduction with the Visual Analog Scale (VAS), functionality with the Oswestry Disability Index (ODI), Patient Global Impression of Change (PGIC) and medication usage were evaluated. Four subjects preferred T9 stimulation with only one subject preferring stimulation at L2. One subject dropped out of the study before conclusion of the 4-week evaluation and is not included in this report. Average pain levels (n=5) at 12-week post-implantation decreased with 61% for back pain and 56% for leg pain with a significant reduction in pain medication, including a 100% reduction in opioid pain medications. The average reduction in disability was 12%. Subjects reported an average impression of change of 6 (1=no change, 7=great deal better). Wireless high-frequency stimulation of the DRG is a viable option to treat chronic low back pain. Preliminary results show a subject preference for stimulation at the T9 vertebral level.

Psoas Muscle Size Predicts Risk-Adjusted Outcomes After Surgical Aortic Valve Replacement

Frailty is an important predictor of outcomes after cardiac surgery, but utility is limited by difficult assessment and quantification. We hypothesize that sarcopenia defined as psoas muscle cross-sectional area is a useful predictor of surgical aortic valve replacement outcomes in moderate to high-risk patients. Moderate to high risk patients (predicted risk of mortality greater than 3%) who underwent surgical aortic valve replacement with or without coronary artery bypass were extracted from an institutional database (2009 to 2016). Psoas index was calculated as the cross-sectional area of the psoas muscle at the L4 vertebral level normalized to body surface area. Patients were stratified by sarcopenia status, defined as less than 25th sex-specific percentile. Multivariable regression analysis identified risk-adjusted associations with psoas index using The Society of Thoracic Surgeons predicted risk scores. Of the 240 patients included, the median predicted risk of mortality was 6%, median age 80 years, and 40% were female. Patients with (33.3%) and without (66.7%) sarcopenia had equivalent baseline risk (median predicted risk of mortality 5.7% versus 6.0%, p= 0.29). Patients with sarcopenia had higher 1-year mortality (31.9% versus 16.9% p= 0.03). Psoas index significantly predicted risk-adjusted 1-year mortality (odds ratio 0.84, p= 0.02) and long-term mortality (hazard ratio 0.92, p= 0.04), as well as risk-adjusted major morbidity, prolonged ventilation, length of stay, discharge to a facility, and hospital cost. Finally, psoas index measurements were highly reproducible (Pearson correlation coefficient 0.944). Psoas index is an easily obtained and reproducible measure of frailty that predicts risk-adjusted resource utilization, morbidity, and long-term mortality. Psoas index may improve procedural selection and risk adjustment in high-risk patients with aortic valve disease.

Minimally Invasive Surgical Approach to Filum Sectioning: Technical Note.

Filum terminale lipoma (FTL) is known to cause various spinal symptoms collectively referred to as tethered cord syndrome (TCS). With the increasing use of magnetic resonance imaging, there has been an increase in the identification of FTLs. The treatment for FTL is surgical untethering by sectioning the filum terminale, which can prevent symptom progression and often results in improvement of symptoms. We recently introduced a new surgical strategy for filum terminale sectioning named interlaminar approach (ILA). In this surgical video, we present a minimally invasive technique of ILA. The surgical approach and postoperative result are outlined. A minimal 2 cm length of midline skin incision was performed at the L5 vertebral level. After skin incision, dissection was extended to expose the ligamentum flavum. The ligamentum flavum was then incised and retracted medially to expose the dural sac. After dural incision, the filum terminale was identified and pulled out from the dural sac and then sectioned. The maximum diameter of the filum terminale was 3 mm in our series. The surgical time for children was about 1 h. Adult patients need a deeper surgical field, so the operation takes more time. Until now, 46 patients (11 mo to 27 yr) have undergone ILA and been followed for more than 5 yr. Surgical complication was seen in only one patient who developed a subcutaneous fluid collection. All patients remained stable or showed improvement in preoperative symptoms. This technique provides the advantage of reduced soft tissue injury and minimal intradural procedures. Thin FTL showing TCS are candidates for ILA. This article complies with the guideline for patient information confidentiality and privacy protection. All the patients in this study provided written, informed consent for the procedure. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx127 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Minimally Invasive Surgical Approach to Filum Sectioning: Technical Note","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_kcc30hx5"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

3:45 PM Abstract No. 287 Increase in muscle mass after transjugular intrahepatic portosystemic shunt (TIPS) creation is a prognostic indicator for survival in cirrhosis

To assess changes in skeletal muscle volume and density after TIPS creation. Patients with cirrhosis undergoing TIPS creation at a single institution between 2004 and 2015, and who had available pre- and post-TIPS contrast-enhanced CT scans, were reviewed (n = 80). Subjects who had received liver transplantation prior to TIPS creation or during the observation period (n = 4) were excluded. Cross sectional muscle area and density (psoas, paraspinal, abdominal wall) were measured with free-hand region of interest at the mid L4 vertebral body level before and after TIPS creation. Differences were compared using the paired t-test. Pairwise correlation analysis was performed to evaluate associations between baseline muscle area and clinical characteristics with post-TIPS changes. Predictors of overall survival were assessed using univariate and multivariate Cox proportional hazard models adjusted for age, sex, HCV infection, hepatocellular carcinoma, diabetes, MELD score and baseline muscle measurements. P values < 0.05 were considered significant. Significant increases in psoas, paraspinal, and total muscle areas were observed after TIPS creation (P <0.001, 0.004, 0.002). A significant increase in post-TIPS psoas muscle attenuation was also observed (3.1 ± 8.5 HU, P = 0.022). In multivariate analysis, increases in psoas (HR = 0.14, P = 0.016), paraspinal (HR = 0.15, P = 0.016), abdominal (HR = 0.05, P = 0.005), core (HR = 0.06, P = 0.001) and total (HR = 0.05, P = 0.003) muscle areas after TIPS creation predicted significantly increased survival rates compared to those with no change. Changes in core muscle area following TIPS creation were not predicted by patient demographics, comorbidities, or pre- and post-TIPS liver function studies. Cross-sectional area of truncal muscles significantly increased after TIPS creation and correlated with improved survival. These parameters can complement other determinants in the assessment of prognosis after TIPS creation. Future research will elucidate the prognostic impact of sarcopenia for TIPS creation, and will increase understanding of potential metabolic changes induced after portosystemic shunting.

Preoperative sarcopenia and post-operative accelerated muscle loss negatively impact survival after resection of pancreatic cancer.

BackgroundSarcopenia and post‐operative accelerated muscle loss leading to cachexia are commonly observed in patients with pancreatic cancer. This study aimed to assess the influence of body compositions and post‐operative muscle change on survival of patients with surgically treated pancreatic cancer.MethodsWe analysed data of patients diagnosed with pancreatic adenocarcinoma who underwent surgery from 2008 to 2015. Skeletal muscle areas, muscle attenuation, and visceral and subcutaneous adipose tissue areas were measured from two sets of computed tomography images at L3 vertebral levels. In addition, muscle change was calculated from images obtained before and after cancer resection. We set our own cut‐off values of various body compositions based on sex‐specific tertiles.ResultsA total of 180 patients were analysed. Patients with perioperative sarcopenia (n = 60) showed poorer overall survival than those without perioperative sarcopenia (P = 0.031). Fifty (28.6%) patients with accelerated muscle loss after surgery (>10%/60 days) had poorer survival compared with the others (P = 0.029). Sarcopenia (hazard ratio, 1.79: 95% confidence interval, 1.20–2.65] and post‐operative muscle change (%/60 days) (hazard ratio, 0.94: 95% confidence interval, 0.92–0.96) were identified as significant predictors of survival on multivariable analyses.ConclusionsPreoperative sarcopenia identified on CT scan was associated with poor overall survival in patients with pancreatic cancer following surgery. Accelerated muscle loss after surgery also negatively impacted survival in pancreatic cancer patients.

Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy.

Total psoas area (TPA), a marker of sarcopenia, has been used as an independent predictor of clinical outcomes in gastrointestinal (GI) cancers as a proxy for frailty and nutritional status. Our study aimed to evaluate whether TPA, in contrast to traditional measurements of nutrition like body mass index (BMI) and body surface area (BSA), was predictive of outcomes in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) patients receiving stereotactic body radiation therapy (SBRT). Retrospective analysis of an institutional review board approved database of 222 BRPC and LAPC treated with SBRT from 2009-2016 yielded 183 patients that met our selection criteria of pre-SBRT computed tomography (CT) imaging with an identifiable L4 vertebra. Once the L4 vertebral level was identified, the bilateral psoas muscles were manually contoured. This area was normalized by patient height, with units described in mm2/m2. Receiver operating characteristic (ROC) curves were generated for TPA, BMI, and BSA to elicit clinically relevant cutoffs. Regression and Kaplan-Meier analyses were used to correlate toxicity with survival functions. Low TPA (OR =1.903, P=0.036) was predictive of acute toxicities, and only TPA was predictive of Grade 3 or higher acute toxicities (OR =10.24, P=0.007). Both findings were independent of tumor resectability. Pain (P=0.003), fatigue (P=0.040), and nausea (P=0.039) were significantly associated with low TPA. No association was identified between any measurement of nutritional status and the development of late toxicities, overall survival, local progression or local recurrence. However, BRPC patients survived longer (median =21.98 months) than their LAPC (median =16.2 months) counterparts (P=0.002), independent of nutritional status. TPA measurement is readily available and more specific than BMI or BSA as a predictor of acute radiotoxic complications following SBRT in BRPC/LAPC patients. A TPA of <500 mm2/m2 is a clinically relevant cutoff that can direct physicians to address expected complications of pain, fatigue, and nausea. However, tumor resectability remains as the only predictor of overall survival in this cohort.

The sarcopenia index: A novel measure of muscle mass in lung transplant candidates.

Frailty, including low muscle mass, is an emerging risk factor for poor outcomes after lung transplant. The sarcopenia index (SI)-(serum creatinine value/cystatin C value)×100-is a novel blood test to approximate muscle mass. We sought to validate SI among lung transplant patients. We retrospectively identified adult lung transplant recipients from 2000 through 2012 at our institution who underwent computed tomography within 1year before transplant and had preserved blood samples. Creatinine and cystatin C values were measured using the samples and used to calculate SI. Muscle mass was estimated by computed tomographic measurement of skeletal muscle cross-sectional surface area (SA) at the L1 to L3 vertebral levels. Correlation between SI and SA was evaluated. Of 28 patients meeting eligibility criteria, most were white (96%) and men (54%). Median (interquartile range) body mass index, SI, and SA were 25.9 (22-30) kg/m2 , 106 (91-119), and 157 (113-195) cm2, respectively. The Pearson correlation coefficient between SI and SA was significant at L2 (0.43; P=.02) and L3 (0.41; P=.03). Sarcopenia index is a potentially objective measure for estimating muscle mass that is noninvasive and less expensive. Sarcopenia index could be considered in lung transplant candidate selection following prospective validation in larger cohorts.

Clinical and Radiologic Characteristics of Deep Lumbosacral Dural Arteriovenous Fistulas.

Spinal dural arteriovenous fistulas located in the deep lumbosacral region are rare and the most difficult to diagnose among spinal dural arteriovenous fistulas located elsewhere in the spinal dura. Specific clinical and radiologic features of these fistulas are still inadequately reported and are the subject of this study. We retrospectively evaluated all data of patients with spinal dural arteriovenous fistulas treated and/or diagnosed in our institution between 1990 and 2017. Twenty patients with deep lumbosacral spinal dural arteriovenous fistulas were included in this study. The most common neurologic findings at the time of admission were paraparesis (85%), sphincter dysfunction (70%), and sensory disturbances (20%). Medullary T2 hyperintensity and contrast enhancement were present in most cases. The filum vein and/or lumbar veins were dilated in 19/20 (95%) patients. Time-resolved contrast-enhanced dynamic MRA indicated a spinal dural arteriovenous fistula at or below the L5 vertebral level in 7/8 (88%) patients who received time-resolved contrast-enhanced dynamic MRA before DSA. A bilateral arterial supply of the fistula was detected via DSA in 5 (25%) patients. Clinical symptoms caused by deep lumbosacral spinal dural arteriovenous fistulas are comparable with those of spinal dural arteriovenous fistulas at other locations. Medullary congestion in association with an enlargement of the filum vein or other lumbar radicular veins is a characteristic finding in these patients. Spinal time-resolved contrast-enhanced dynamic MRA facilitates the detection of the drainage vein and helps to localize deep lumbosacral-located fistulas with a high sensitivity before DSA. Definite detection of these fistulas remains challenging and requires sufficient visualization of the fistula-supplying arteries and draining veins by conventional spinal angiography.

Neurólise do plexo celíaco

Os autores relatam a experiência com dez pacientes portadores de dor visceral abdominal alta, decorrente de tumores da cabeça do pâncreas, cisto do pâncreas, tumores das vias biliares, do estômago e do cólon e metástase abdominal, submetidos à neurólise do plexo celíaco, por via póstero-lateral, com álcool absoluto, sob neuroleptoanalgesia e controle radioscópico. Utilizando-se uma agulha de aortografia, tipo Santos, a cada lado, procedeu-se à neurólise bilateral do plexo celíaco, entrando-se a 8 cm da linha média, a altura do corpo vertebral de L1, na interseção da última costela e a uma angulação de 45º com a horizontal. Previamente à introdução do agente neurolítico, a cada lado, foram injetados 5 ml de xilocaína a 2% sem vasocontrictor, com a finalidade de obter confirmação clínica do perfeito posicionamento da agulho pelo desaparecimento da dor e pela hipotensão arterial leve. Após à injeção do álcool absoluto, introduzimos corticosteróides de depósito, a cada lado, para redução da nação inflamatória e da dor local. Todos os pacientes apresentaram melhora imediata da dor, sendo hipotensão arterial a complicação mais frequente, não lendo havido complicações neurológicas.

Is sarcopenia and sarcopenic obesity associated with clinical and pathological outcomes in patients undergoing radical nephroureterectomy?

PurposeTo investigate the association between sarcopenia and sarcopenic obesity on clinical, perioperative, and oncologic outcomes in patients with upper-tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). MethodsRetrospective review of our institutional UTUC database was performed to identify all patients who underwent radical nephroureterectomy from 2002–2016. Skeletal Muscle Index (SMI) was measured at the L3 vertebral level and standardized according to patient height (cm2/m2). Sarcopenia was defined as<55cm2/m2 for men and<39cm2/m2 for women. Sarcopenic obesity was also assessed in patients with BMI>30kg/m2. Unadjusted logistic regression and Wilcoxon rank sum tests examined the relationship between sarcopenia and variables. ResultsA total of 100 patients (66 men and 34 women) with a mean age of 68 years, BMI of 30, Charlson comorbidity index of 4.0, tumor size of 3.5, and SMI of 50.8cm2/m2 were included. Furthermore, 42 patients (42%) were sarcopenic, and 18 patients (18%) had sarcopenic obesity. Median EBL was 150ml, OR duration was 322 minutes, and length of stay was 5.0 days. Sarcopenia was associated with several clinical factors including decreasing BMI, male sex, and coronary artery disease, albeit without association with any perioperative or oncologic outcomes. Sarcopenic obesity was similarly associated with several clinical variables including male sex, diabetes mellitus, hyperlipidemia, as well as increased EBL (P = 0.047) and non–bladder cancer disease relapse (P = 0.049). ConclusionsThis contemporary cohort of patients undergoing RNU highlights the association of nonmodifiable risk factors with sarcopenia and disease relapse with sarcopenic obesity. Larger studies are necessary to further validate these observations.

Crus Atrophy: Accuracy of Computed Tomography in Diagnosis of Diaphragmatic Paralysis.

The aim of this study was to measure the association between crus atrophy as depicted by computed tomography (CT) and fluoroscopic diagnosis of hemidiaphragmatic paralysis in patients with suspected diaphragmatic dysfunction. A retrospective review of patient data was approved by our institutional review board and was HIPPA-compliant. We reviewed 90 patients who had undergone diaphragmatic fluoroscopy; 72 had CT scans available for measurement of crus thickness at the levels of the celiac and superior mesenteric arteries and the L1 vertebral body. Receiver operating characteristic analysis was used to determine the threshold of crus thinning that best distinguished a paralyzed hemidiaphragm from a nonparalyzed one. Hemidiaphragmatic paralysis caused significant crus thinning at the celiac artery level (mean±SD, 1.7±0.6 vs. 3.6±1.3 mm, P=0.017, on the right; 1.1±0.4 vs. 3.0±1.4 mm, P=0.001, on the left) and the L1 vertebral level (mean±SD, 1.5±0.7 vs. 4.4±1.6 mm, P=0.018, on the right; 1.5±0.6 vs. 3.6+1.7 mm, P=0.017, on the left). On axial CT, thinning to ≤2.5 mm at the celiac artery level identified paralysis of the hemidiaphragm with a sensitivity of 100% and a specificity of 86% on the right and with a sensitivity of 100% and a specificity of 64% on the left. On coronal CT, thinning to ≤2.5 mm at the L1 vertebral level identified paralysis of the hemidiaphragm with a sensitivity of 100% and a specificity of 88% on the right and with a sensitivity of 100% and a specificity of 77% on the left. Atrophy of the crus assessed by CT is a good discriminator of paralyzed versus nonparalyzed hemidiaphragm in patients with suspected diaphragmatic dysfunction.

Does Temperature Increase by Sympathetic Neurolysis Improve Pain in Complex Regional Pain Syndrome? A Retrospective Cohort Study.

Lumbar sympathetic neurolysis (LSN) is a treatment option for complex regional pain syndrome (CRPS). We examined whether LSN-related temperature changes are associated with clinical outcome and investigated relationships between the outcome of LSN and clinical variables in patients with CRPS-I. We included 95 patients with CRPS-I affecting a single lower extremity, by the Budapest criteria, and who underwent LSN after successful lumbar sympathetic blocks, in this retrospective study. Fluoroscopy-guided LSN was conducted with 1.5 mL of 99% alcohol at L2 and L3 vertebral levels. Positive outcome was defined as a reduction of ≥50% on a numeric rating scale pain score at 6 months after LSN. The relationship between successful outcome and clinical variables was analyzed. Positive LSN outcome occurred in 49.5% of patients, and it was suggested that Sympathetically maintained pain may accompany CRPS-I in 28% of patients. The overall temperature in the affected limb was increased after LSN, without contralateral limb temperature changes, but did not differ significantly between the positive and negative outcome groups (P= 0.590). Temperature after LSN in warm-type CRPS was reduced in the affected limb, without contralateral limb temperature changes. The absolute temperature change was significantly greater in cold-type than in warm-type CRPS (P= 0.026). In multivariate analysis, a short duration of pain and concurrent cold intolerance were significant factors predicting a positive outcome after LSN. LSN may be effective in some patients with CRPS, irrespective of temperature changes and temperature asymmetry pattern. A short duration of pain and concurrent cold intolerance significantly predict successful LSN.

PAM50: Unbiased multimodal template of the brainstem and spinal cord aligned with the ICBM152 space

Template-based analysis of multi-parametric MRI data of the spinal cord sets the foundation for standardization and reproducibility, thereby helping the discovery of new biomarkers of spinal-related diseases. While MRI templates of the spinal cord have been recently introduced, none of them cover the entire spinal cord. In this study, we introduced an unbiased multimodal MRI template of the spinal cord and the brainstem, called PAM50, which is anatomically compatible with the ICBM152 brain template and uses the same coordinate system. The PAM50 template is based on 50 healthy subjects, covers the full spinal cord (C1 to L2 vertebral levels) and the brainstem, is available for T1-, T2-and T2*-weighted MRI contrasts and includes a probabilistic atlas of the gray matter and white matter tracts. Template creation accuracy was assessed by computing the mean and maximum distance error between each individual spinal cord centerline and the PAM50 centerline, after registration to the template. Results showed high accuracy for both T1- (mean = 0.37 ± 0.06 mm; max = 1.39 ± 0.58 mm) and T2-weighted (mean = 0.11 ± 0.03 mm; max = 0.71 ± 0.27 mm) contrasts. Additionally, the preservation of the spinal cord topology during the template creation process was verified by comparing the cross-sectional area (CSA) profile, averaged over all subjects, and the CSA profile of the PAM50 template. The fusion of the PAM50 and ICBM152 templates will facilitate group and multi-center studies of combined brain and spinal cord MRI, and enable the use of existing atlases of the brainstem compatible with the ICBM space.

Can Total Psoas Area Predict Toxicity After Stereotactic Body Radiation Therapy in Borderline Resectable and Locally Advanced Pancreatic Cancers?

455Background: Total Psoas Area (TPA), a marker of sarcopenia, found clinical utility as an independent predictor of clinical outcomes in gastrointestinal cancers as a proxy for nutritional status. Our study evaluated the relationship of TPA and other proxies of nutrition like Body Mass Index (BMI) and Body Surface Area (BSA) with outcomes in Borderline Resectable Pancreatic Cancer (BRPC) and Locally Advanced Pancreatic Cancer (LAPC) patients receiving Stereotactic Body Radiation Therapy (SBRT). Methods: In retrospective analysis of an IRB approved database, 183 BRPC and LAPC patients treated with SBRT from 2009-2016 met our selection criteria. Patients underwent gemcitabine based or FOLFIRINOX chemotherapy for 3 months prior to SBRT. Eligible patients were those with pre-SBRT planning CT imaging on Pinnacle, a treatment planning system, and an identifiable L4 vertebra. Bilateral psoas muscles were manually contoured at the L4 vertebral level. This area was normalized by patient height (median = 876.505 m...

Prognostic Significance of Sarcopenia for Patients Treated by Surgery and Radiation for Uterine Cancer

Sarcopenia (low skeletal muscle mass) has recently been recognized as an independent indicator of poor prognosis in newly-diagnosed cancer patients, regardless of baseline body mass index. Although the underlying mechanism remains unknown, sarcopenia has traditionally been associated with poor tolerance and compliance to treatment, including chemotherapy and surgery. Since patients undergoing radiation therapy for uterine cancer, many of whom are overweight and/or obese, might be at particularly high risk for clinically unrecognized sarcopenia, they comprise a potentially ideal group to investigate its prognostic significance. The medical records of consecutive patients treated for histologically-proven uterine cancer at a tertiary-care academic medical center between 2007 and 2015 were reviewed. Analysis was limited to newly-diagnosed patients receiving definitive surgery and external beam radiation with or without chemotherapy. Sarcopenia was objectively defined as skeletal muscle index (SMI) of < 41 cm2/m2, a previously validated measure. SMI calculations were based on radiation treatment planning computed tomography (CT) scans, using the average skeletal muscle cross sectional areas of two sequential axial CT slices at the L3 vertebral level. A single trained observer performed image analysis using NIH ImageJ software with a Hounsfield unit threshold of -29 to 150 to define skeletal muscle. Actuarial estimate of overall survival and progression-free survival were calculated using the Kaplan-Meier method with comparison between groups performed using the log-rank test. Forty-five patients satisfied inclusion criteria. Eighty-seven percent of patients in our study population were overweight or obese (as defined by body mass index greater than 25), and 42% met our standardized definition for sarcopenia. Stage and tumor histology did not differ, although sarcopenic patients were significantly more elderly than those without sarcopenia (median 66.3 vs 58.2 years, p=0.02). Sarcopenic patients were also more likely to miss one or more cycles of planned chemotherapy (35% vs 5%, p=0.04), but unplanned missed radiation treatment days or likelihood of completing planned radiation therapy did not differ. There was a trend towards decreased overall survival in sarcopenic versus non-sarcopenic patients (median: 2.7 versus 3.1 years, p=0.12), but progression free survival did not differ (median 1.3 versus 1.7 years, p=0.62). Sarcopenia is common in uterine cancer patients undergoing perioperative external beam radiation therapy and is associated with poor tolerance of chemotherapy, but not radiation. A trend was identified suggesting decreased overall survival for patients with sarcopenia.

Impact of sarcopenia on outcomes of locally advanced esophageal cancer patients treated with neoadjuvant chemoradiation followed by surgery.

Sarcopenia is an independent predictor of clinical outcomes in multiple gastrointestinal cancers. Total psoas area (TPA), as measured on a single cross-sectional CT image at the L4 vertebral body level, has been correlated with sarcopenia. We sought to evaluate whether TPA was predictive of acute grade ≥3 toxicity, pathologic response, and overall survival in patients with locally advanced esophageal cancer receiving tri-modality therapy. An institutional database of esophageal cancer patients treated with neoadjuvant chemoradiation followed by surgery was queried. Of 77 patients treated from 2008 to 2012 with intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT), 56 patients were eligible based on having CT imaging that included the L4 vertebral body. The L4 vertebra was identified on axial CT and the psoas muscle was manually contoured bilaterally to determine the skeletal muscle index. Sarcopenia was defined by the presence of the psoas area less than the median of the cohort. Acute toxicity was defined as within 3 months of radiotherapy based on Common Terminology Criteria for Adverse Events. ROC curve, logistic regression, and Kaplan Meier estimates were used when appropriate. Sarcopenia was associated with increased acute grade ≥3 toxicity from chemoradiation by ROC analysis using a cut off of 841.5 mm2/m2 (P=0.003, AUC 0.709, sensitivity 60.9%, specificity 78.8%) and logistic regression (P=0.002). Patients with TPA <841.5 mm2/m2 were 5.78 times more likely to develop grade 3 or higher toxicity (P=0.004). Sarcopenia did not predict a difference in overall survival (P=0.217) and was not significant for pathologic complete response or favorable pathologic response (TRG 0/1). In our cohort of patients, sarcopenia was associated with a significant increase in acute grade ≥3 toxicity with chemoradiation, suggesting a potential role for neoadjuvant patient selection strategies. There was no difference in pathologic response or overall survival.

The feasibility of building the oblique lumbar interbody fusion corridor: A CT image study

Objective To determine the radiographic feasibility of oblique lumbar interbody fusion (OLIF) corridor to treat lumbar disease at each lumbar disc level, including the corridor's numerical value and the influence of diaphragmatic crura and aorta abdominalis. Methods A retrospective CT study was conducted on 110 patients (including 69 males and 41 females, average age 47.95 years, range 16-83 years) that continuously collected and analyzed in the PACS system. The oblique corridor was defined as the area between the left lateral border of the aorta abdominalis(or iliac artery) and the right lateral border of the left psoas. The distances and angles of L1-2, L2-3, L3-4 and L4-5 levels were measured. Whether the change of diaphragmatic crura and aorta abdominalis affected the building of the corridor was also observed. Results The mean distances of oblique corridor to the levels of L1-L5 discs were: L1-2 15.90 mm, L2-3 14.82 mm, L3-4 17.57 mm, L4-5 11.16 mm. At the levels of L1-2 and L3-4, all of the images could build the corridor. But there were only 97.27% images allowing operation at both L2-3 and L4-5, and the other 3 cases couldn't build the corridor since the aorta abdominalis was very close to psoas, and the distance was almost 0 mm. The max mean distance was 36.79 mm at L3-4 level. The mean angles were: L1-2 36.98˚; L2-3 37.76˚; L3-4 40.96˚; L4-5 37.85˚. The significant difference was at L3-4, ranged from 13.09 to 61.93˚. The level of the aortic bifurcation was from the lower third of the L3 vertebral body to the middle third of the L5 vertebral body. The levels of left diaphragmatic crura's ending point in the lumbar was divided into four groups: 1) Group L1 vertebral body level: the level at L1 vertebral body and above, 5 cases (4.55%); Group L1-2 disc to L2 vertebral body level: at L1-2 disc and L2 vertebral body, 67 cases (60.91%); Group L2-3 disc to L3 vertebral body level: at L2-3 disc and L3 vertebral body, 36 cases (32.72%); Group L3-4 disc to L4 vertebral body level: at L3-4 disc and L4 vertebral body, 2 case (1.81%). Conclusion The OLIF corridor can be built successfully at L1-2 and L3-4. However, it may be difficult at L2-3 and L4-5 for some patients due to the aorta abdominalis which is too close to psoas. The angles of L1-L5 levels were similar. While the left diaphragmatic crura was mainly impact the corridor insertion at L1-2 and L2-3. And the level of the aortic bifurcation was mainly located at the upper endplate of L4 to the L4-5 disc (87%). Key words: Lumbar vertebrae; Spinal fusion; Aorta, abdominal; Diaphragm; Tomography, spiral computed

Abdominal-pelvic scanning parameters revisited: a case for Z-axis reduction in patients with clinical suspicion for acute appendicitis.

The purpose of this study was to determine if CT for appendicitis can be abbreviated to begin at the top of the L2 vertebral body level and still maintain the detection rate of appendicitis and other symptomatic pathology without omitting significant incidental findings. Retrospective review of CT abdomen-pelvis exams for suspected appendicitis over a 5-month period was performed. The Z-axis scan length of the original full scans and theoretical limited scans from the top of L2 were recorded and calculated. Images were reviewed for incidental findings above the L2 vertebral body level and categorized by severity per American College of Radiology (ACR) white paper guidelines. Final diagnoses based on imaging findings were also recorded. One hundred nineteen patients (46 males, 73 females, mean age 29±14) were included. Appendicitis was present in 26 cases (22%). Using a theoretical scan beginning at the top of the L2 vertebral body, none of the findings leading to diagnosis of appendicitis would have been missed. A total of 30 incidental findings were found above the L2 vertebral body. Per ACR white paper guidelines, 26 of these findings did not require additional imaging follow-up. Additional follow-up imaging was recommended for 3 of the findings above L2, and 1 right adrenal metastasis was found above L2 in a patient with previously undiagnosed NSCLC. This patient coincidentally also had appendicitis. No symptomatic pathology would have been missed had the scans begun at the top of the L2 vertebral body. Such an abbreviated scan would have resulted in a mean Z-axis reduction of 12.9cm (30.3%). CT using abbreviated Z-axis scan length can reduce radiation dose and provide necessary imaging needed to diagnose appendicitis or other symptomatic pathology without omitting significant incidental findings.

Multiple level spondylodiscitis with presacral abscess in spinal brucellosis: a rare presentation

Importance: We report an unusual presentation of spinal brucellosis involving multilevel spondylodiscitis, prevertebral sacral abscess and isolation of Brucella using a low-yield test like blood culture. Timely identification helped in dispensing the appropriate antibiotic regimen.Observation:Detailed history against an endemic background may give clues to diagnosis of brucellosis. A middle aged farmer from rural India with exposure to cattle excreta presented with severe lower backache and asymmetric paraparesis. Examination revealed proximal lower limb weakness, sensory deficits over L1-L2 dermatomes, sensory level at L1 vertebral level and lumbosacral spinal tenderness with paravertebral muscle spasms. MRI spine with contrast showed multi-level infective spondylodiscitis with a prevertebral sacral abscess. Blood culture helped isolate Brucella melitensis after 8 days. Following this the antibiotic regimen was modified to a twelve month triple therapy with rifampicin, doxycycline and double strength cotrimoxazole.Conclusions and Relevance: Longstanding backache with fever in endemic areas should trigger a differential diagnosis of spinal brucellosis. Though newer diagnostic techniques like ELISA, MRI and agglutination tests are being increasingly used, isolation of Brucella on culture media is still a vital investigation. Diagnosis of brucellosis is vital owing to its potential treatability.

Low Back Injury - Football

HISTORY: A 23 year old division I football player presented for recurrent back pain after two separate injuries at practice. He has a prior history of left sided low back pain and spasm which responded well to mobilization treatments. However, during a power lifting session he felt increased pain with radiation down the left leg with extension maneuvers. At a subsequent practice, he rotated to grab a ball and noted significant right sided low back pain. PHYSICAL EXAMINATION: Full flexion, extension, sidebending, and rotation at waist Bilateral lumbar paravertebrals are tight and TTP, worse on left. Left SI region TTP. Spinous processes are non-tender. Full sensation in bilateral LE L2-S1 dermatomes 5/5 strength in bilateral LE L3-S1 myotomes 2+ patellar and achilles reflexes bilaterally. No clonus. SLR equivocal left, negative right. Slump test positive left, negative right. Stork test with mild discomfort left, negative right. DIFFERENTIAL DIAGNOSIS: 1. Lumbar radiculopathy 2. Lumbar paraspinal strain 3. Spondylolysis 4. Spondylolisthesis 5. Degenerative disc disease TEST AND RESULTS: XR L-spine, AP/Lat/Flexion/Extension views: Negative MRI L-spine: 1. Stress fracture with nondisplaced fracture of anterior pedicle on left and pars interarticularis on right of L4. Early stress injury without fracture at the pedicle and pars interarticularis of L5. 2. Left paracentral protrusion compressing left S1 nerve root at L5-S1. CT scan L-spine: Bilateral posterior element fractures at L4 vertebral body level, involving right lamina and pars interarticularis and left pedicle. No evidence of spondylolisthesis. FINAL WORKING DIAGNOSIS: Left L4 pedicle fracture. Right L4 pars fracture. Bilateral L5 pars and pedicle stress reactions. L5-S1 disc protrusion with left S1 nerve root compression. TREATMENT AND OUTCOMES: 1. L4-L5 and L5-S1 transforaminal epidural steroid injections: Complete resolution of leg pain. 2. Restricted from practice, weight lifting, and extension activities for 4 weeks with LSO brace. 3. Returned to running at 4 weeks, progressed to non-contact drills without pain. 4. Progressed to full contact practice and game play at 8 weeks without pain. 5. Plan for surgical fixation with screws at end of season with 3 to 6 month recovery. 6. If any setbacks, will be withheld from football and plan for earlier surgery.