Left Psoas Research Articles

Oblique lumbar interbody fusion in management of lumbar degenerative spinal stenosis in Chinese population

Purpose: The purpose of this study was to assess the outcomes of a cohort of local Chinese patients who underwent oblique lumbar interbody fusion (OLIF) surgery for lumbar degenerative diseases. Methods: We adopted a minimally invasive anterior approach to the lumbar spine through retroperitoneal access. In the first part of the surgery, a 3- to 5-cm left lateral incision over the abdomen was made guided by imaging. L2–L5 disc space was approached via the corridor between the left psoas muscle and the great vessels. A specially designed interbody cage filled with bone substitute was utilized for interbody fusion. In the second part of the surgery, posterior instrumentation with or without decompression, was performed in a prone position. Efficacy and safety of the surgery were studied. Results: A total of 60 patients with the mean age of 68 years underwent OLIF at 83 surgical levels. Their mean operative time was 79 min, and the average blood loss was 84 ml for the OLIF part. The mean length of hospital stay was 5.5 days. Based on plain computed tomography scan obtained at post-operative 6 months, successful fusion was achieved in 82 of the 83 surgical levels. The Oswestry Disability Index for low back pain had a mean reduction of 22.3% after 6 months. Specific complications observed include transient thigh pain or numbness, retroperitoneal hematoma, post-operative ileus and Bone Morphogenetic Protein (BMP) osteolysis. None of the patients experienced infection, symptomatic pseudo-arthrosis, hardware failure, vascular injury, nerve injury, ureteral injury, bowel injury, incisional hernia or death. Conclusion: OLIF is an effective procedure to treat lumbar spinal stenosis and spondylolisthesis with excellent fusion rate and good functional outcome. Complications specific to this procedure are not uncommon, but majority are minor and self-recovery. Proper training is required to minimize potential surgical risks.

MON-918 Familial Paraganglioma: Familiar Case Report

Introduction: Pheochromocytomas and Paragangliomas (PGL) are rare tumors originating from chromaffin cells. They may be sporadic or associated with familial inherited genetic syndromes around 50-80%. There are several PGL syndromes, the most common being PGL 1 (SDHD mutations), PGL 2 (SDHAF), PGL 3 (SDHC), PGL 4 (SDHB), PGL 5 (SDHA), PGL 6 (SLC25A11) and PGL 7 (DLST). SDHB mutations generate a higher probability of malignant PGL, as well as risk of renal, GIST and pituitary neoplasms. We report the case of a patient with a positive family history for the autosomal dominant SDHB mutation.Clinical cases: FZR, male, 19 years old, history of headache, sweating, palpitations, and sudden onset tremors associated with hypertensive peaks. Physical examination: Blood Pressure 140x90mmHg lying down, 110x70 standing up. Performed examinations, of which altered, showed: Plasma metanephrines: 82 pg/mL (RV <65), Plasma normetanephrines: 1.488pg/mL (VR <196), Urinary Catecholamines: 1.784mcg/24h (RV: 80-500), Abdomen Resonance showed an expansive, solid, heterogeneous abdomen mass in posterior contact with the left psoas muscle, medial with the aorta, and lateral with jejunum loops, measuring 7x3.5 cm. MIBG scintigraphy: abnormal uptake in left kidney. Family history: uncle diagnosed with cervical paraganglioma with cervical lymph node metastasis, gastric GIST and PCR genetic sequencing identifying mutation in SDHB (Q.137 G > T in exon 2). Asymptomatic second cousin with positive genetic analysis for the same mutation and another deceased first cousin diagnosed with pheochromocytoma with bone metastasis. He underwent tumor resection that identified retroperitoneal paraganglioma with 10% KI67, Protein S-100, Chromogranin-A and Synaptophysin positive. Carried out PCR genetic analysis that identified the same Q.137 G > T mutation in exon 2 of the SDHB gene in heterozygosis.Twenty-six relatives were called for mutation research, of which 5 positive for the SDHB mutation, until now, including the patient’s mother and twin brother, both already investigating related diseases.We await new family members and, subsequently, the result of the mutation analysis to continue the clinical and laboratory follow-up of this family.Conclusion: Although rare, this condition should be remembered as a differential diagnosis of diseases with such clinical symptoms and, once characterized, investigate possible associations with genetic syndromes.

The OLIF working corridor based on magnetic resonance imaging: a retrospective research

ObjectiveTo provide an anatomical basis for the development of oblique lumbar interbody fusion (OLIF) in Chinese patients.MethodsBetween November 2018 and June 2019, 300 patients’ lumbar MRI data were reviewed. According to the Moro system and zone method described by us, the axial view was vertically divided into 6 zones (A, I II, III, IV, P) and was horizontally divided into 4 zones (R, a, b, c, L). The locations of left psoas muscle and the major artery at L2/3, L3/4, and L4/5 levels were evaluated by the grid system. The aortic bifurcation segments will also be evaluated at the level of the vertebral body or the disc.ResultsAt the L2/3 level, left psoas muscle and the major artery in zone Ib were found in 28.0% of subjects, in zone IIb in 20.3%, and in zone Ic in 20.0%; at the L3/4 level, in zone Ab in 20.7% of subjects, in zone Ac in 26.0%, and in zone Ic in 11.0%; and at the L4/5 level, areas in zone Ab in 31.0% of subjects, in zone Ac in 26.0%, and in zone Ib in 11.7%. The aortic bifurcation segments were mainly at the L4 level. The zone of the left psoas muscle at all levels, the zone of the major artery at L4/5 level, and the zone of the aortic bifurcation segments had significant correlation with gender difference (P < 0.05).ConclusionThe left-sided OLIF at L2–L5 disc levels can be a feasible type of surgery for lumbar interbody fusion in the majority of Chinese patients. Before the operation, in order to screen out the appropriate surgical approach, routine lumbar magnetic resonance imaging is recommended to analyze the patient’s local anatomical features.

Psoas Muscle Area Measured with Computed Tomography at Admission to Intensive Care Unit: Prediction of In-Hospital Mortality in Patients with Pulmonary Embolism.

Aim Sarcopenia, a core component of physical frailty, is an independent risk factor for suboptimal health outcomes in hospitalized patients, especially in the intensive care patients. Psoas muscle areas can be assessed to identify sarcopenia. The aim of this study was to determine the prognostic value of psoas muscle area measured with CT for the prediction of in-hospital mortality in patients with pulmonary embolism at admission to the intensive care unit. Methods Patients with an admission abdominal computed tomography scan and requiring intensive care unit (ICU) stay were reviewed. Selected clinical data of patients admitted to intensive care unit for the management of pulmonary embolism were collected. Using CT scan images at the level of L3 vertebra, the psoas muscle area value was obtained by dividing the sum of the right and left psoas muscle areas into the body surface area. Results In-hospital mortality rate was 22.5% in 89 patients. The pulmonary embolism patients with in-hospital mortality had higher PESI and lower value of psoas muscle area, in addition to the lower systolic blood pressure and arterial oxygen saturation at admission. The increase in the value of psoas muscle area is associated with a decrease in the rate of in-hospital mortality. In patients with in-hospital mortality related to pulmonary embolism, the higher PESI and the lower value of psoas muscle area were considered in accordance with the outcome of patients. Conclusions For the prediction of in-hospital mortality risk in patients with pulmonary embolism managed in intensive care unit, the psoas muscle area value has a merit to be used among the routine diagnostic procedures after further studies conducted with different severity of pulmonary embolism.

Effect of Sarcopenia on Mortality after Percutaneous Vertebral Augmentation Treatment for Osteoporotic Vertebral Compression Fractures in Elderly Patients: A Retrospective Cohort Study

The aim to evaluate central sarcopenia, as measured by psoas cross-sectional area on admission imaging, is associated with outcomes in patients with vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation treatment. We evaluated the records of patients aged >60 years treated with vertebroplasty or kyphoplasty between 2009 and 2018 for osteoporotic VCFs. The Social Security Death Index was used to determine death. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. A multivariate Cox algorithm was applied to recognize factors independently associated with survival. A total of 103 patients were included with an average age of 72.3 years. During the study period, 22 (21.4%) patients were deceased, whereas 81 (78.6%) were alive. The survival rates at 1 month, 6 months, and 1 year after surgery were 99%, 94.1%, and 88.4%, respectively. PLVI measurements ranged from 0.24-1.19 with a mean of 0.59 ± 0.17 and a median of 0.603. A total of 51 patients with a median value of 0.603 were defined as low PLVI group, and 52 patients with a median value of ≥0.603 were defined as the high PLVI group. PLVI was significantly low in patients who died. Age, American Society of Anesthesiologists score, and PLVI value were independently associated with a poor overall survival. There is a significant correlation between sarcopenia and postoperative mortality after vertebral augmentation procedure in patients with VCFs.

“There is more than what meets the eye” – Extensive spinal tuberculosis presenting as ocular tuberculosis

Ocular tuberculosis (OTB) is a rare form of extrapulmonary Tuberculosis (EPTB) and a rare presenting feature of tuberculosis (TB) in children. We report such a case in a 3-year-old boy who presented with a painless swelling over left upper eyelid. Mycobacterium tuberculosis bacilli were isolated from the swelling by a Fine Needle Aspiration Cytology (FNAC) which confirmed the diagnosis. Investigating him for the extent of disease, we found him to have intracranial extension to involve the ethmoid sinus on contrast enhance Computed Tomography and Pott's disease causing a compression fracture of L3 with bilateral paravertebral collection, epidural extension and a left psoas abscess on Magnetic Resonance Imaging. After starting antitubercular therapy, the child is doing well and on regular follow up. We are presenting this case to highlight the fact that extensive spinal tuberculosis can present without any neurological deficit and may even present only as a benign looking orbital swelling.

Lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia in a patient with end-stage renal disease: a case report

BackgroundActinomycosis is a chronic, slowly progressive infection caused by the Actinomyces species. Lumbar vertebral involvement of Actinomyces israelii is extremely rare; this is the first case report of lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia.Case presentationA 66-year-old Japanese man with end-stage renal disease was admitted to our hospital for an operation for cervical canal stenosis. After the operation under general anesthesia, during which tracheal intubation and nasogastric tube insertion were performed, he developed low back pain. During a second hospitalization, computed tomography revealed osteolysis of the lumbar endplates of L2 and L3, swelling of the intervertebral disk of L2/L3, and swelling of the left psoas major muscle. Percutaneous drainage of the intervertebral disc was performed, and the culture of the aspirate grew Actinomyces israelii. Based on the susceptibility, ampicillin was administered but his condition did not improve. We changed the antibiotics to ampicillin-sulbactam for coverage of unidentified oral commensals, and his symptoms and signs finally improved.ConclusionOur patient’s long-term end-stage renal disease had made the oral and gastrointestinal mucosal barriers very fragile. Under these conditions, even mildly invasive procedures such as tracheal intubation and nasogastric tube insertion could be the cause of infectious complication by oral commensals, including Actinomyces.

Atypical presentation of Lemierre\u2019s syndrome: case report and literature review

BackgroundThe classic Lemierre’s syndrome refers to a septic thrombosis of the internal jugular vein, usually caused by a Fusobacterium necrophorum infection starting in the oral cavity, and typically complicated by pulmonary emboli. However, unusual forms of the disorder have been rarely reported.Case presentationWe describe an unusual case of a previously healthy 58-year-old male with Lemierre’s syndrome, manifesting with lumbar pain and fever. A thrombosis of the iliac veins and abscesses in the right iliac and the left psoas muscles was diagnosed by a computed tomography scan, together with a right lung pneumonia complicated by pleural effusion and an L4-L5 spondylodiscitis. Blood culture and pus drainage were positive for Fusobacterium nucleatum and an atypical Lemierre’s syndrome was suspected. The patient was treated with anticoagulant therapy for 12 weeks and intravenous antibiotic therapy for 6 weeks with a good evolution and resolution of the thrombosis.ConclusionsThis case illustrates the thrombogenic and thromboembolic tendency of Fusobacterium nucleatum and its potential invasiveness, regardless of the site of primary infection. The concept of an atypical Lemierre’s syndrome is redefined here to take into consideration non-cervical sites.

1499 Segmental Colitis Associated With Diverticulosis (SCAD): A Rare Cause of Hydroureteronephrosis

INTRODUCTION: Segmental Colitis Associated with Diverticulosis (SCAD) is a rare inflammatory condition affecting segments of bowel with diverticulosis. We present a case of a patient with imaging revealing left colonic wall thickening and left sided hydroureteronephrosis, and work-up confirming a diagnosis of SCAD. CASE DESCRIPTION/METHODS: An 85-year-old female with a history of cognitive impairment, uterine cancer status post hysterectomy, and previous episode of diverticulitis 5 years prior presented to our institution with fevers, chills, and flank pain. Symptoms began 3 days prior to presentation with no associated abdominal pain, nausea, vomiting, hematochezia, or changes to her bowel movements. Upon arrival, her vital signs were within normal limits and physical exam disclosed left flank tenderness. Laboratory data revealed leukocytosis to 17 K/uL with unremarkable hematocrit, basic metabolic panel, and liver chemistries. Urinalysis was positive for pyuria with nitrites and leukocytes. CT abdomen and pelvis revealed short segment of sigmoid colonic, adjacent lymphadenopathy, left psoas abscess, and moderate left hydroureteronephrosis (Figure 1). She was initially treated with antibiotics and left-sided percutaneous nephrostomy tube placement. Colonoscopy was deferred due to concern for high risk of complications in favor of conservative management; however, repeat imaging 4 weeks later revealed unchanged thickening of the mid-sigmoid colon extending into left pelvic sidewall and interval increase in the left psoas collection with concern for fistulizing chronic diverticulitis or potential malignancy. She subsequently underwent exploratory laparotomy with lower anterior resection and ileoclonic resection for tethered and fistulizing small bowel to a left lower quadrant phlegmon. The sigmoid colon was also attached to the phlegmon and pathology revealed diverticulitis with extensive old fibrosis and reactive lymphadenopathy without evidence of malignancy or histology suggestive of IBD. As such, the final diagnosis was SCAD-associated hydroureteronephrosis, and she recovered well without complication. DISCUSSION: Often mistaken for IBD or colorectal cancer, SCAD is an inflammatory condition that should be considered in patients with history of diverticulosis and features suspicious for segmental colonic inflammation. This case reinforces understanding and highlights hydroureteronephrosis as a rare complication seen in a patient with SCAD.

Does the hip positioning matter for oblique lumbar interbody fusion approach? A morphometric study.

To evaluate whether left hip positioning widened the access corridor using oblique lateral interbody fusion (OLIF) approach during right lateral decubitus (RLD). Ten healthy adult volunteers underwent a T2 lumbosacral MRI (1.5T) in the supine position, RLD position with left hip in extension and then in flexion. L2-L3 to L5-S1 disc spaces were identified. At each level, left psoas surface (in cm2), access corridor (in mm) and vessel movement were calculated in the three positions. Paired t test was used for comparison. The mean surface of the left psoas ranged from 7.83 to 17.19cm2 in the three positions (p>0.05). From L2-3 to L4-5, in RLD, when the left hip shifted from extension to flexion, nor the access corridor nor vessel movements were significantly different. When the volunteers shifted from supine to RLD position with hip in extension, arteries moved 3.66-5.61mm to the right (p<0.05 at L2-3, L3-4 and L5-S1), while the venous structures moved 0.92-4.96mm (p<0.05 at L2-3) to the right. When the position shifted from supine to RLD with hip in flexion, the arterial structures moved 0.47-4.88mm (p<0.05 at L2-3 and L3-4) to the right, while the venous structures moved -0.94 to 4.13mm (p<0.05 at L2-3 and L3-4) to the right. Hip positioning was not associated with a significant widening of the surgical corridor. To perform OLIF, we advocate for RLD position with left hip in extension to move away the vascular structures and reduce the psoas volume. These slides can be retrieved under Electronic Supplementary Material.

A case report of dengue haemorrhagic fever complicated with psoas haematoma requiring blood transfusion

BackgroundDengue fever is a common infection with increasing numbers of patients affected. Muscle haematomas are a rare complication of dengue fever. In most cases haematomas resolve spontaneously.Case presentationWe report a case of spontaneous psoas muscle haematoma, formed during the critical phase of dengue haemorrhagic fever. A 28-year-old gentleman presented with features of severe dengue and was admitted to the Dengue High Dependency Unit. He was treated with intravenous fluid therapy and supportive measures, and gradually improved initially. However, as the critical phase ended, he suddenly developed pain in the left groin and inguinal region and physical examination was normal. Ultrasound scan revealed a left psoas haematoma. As the patient deteriorated haemodynamically blood was transfused. He recovered without further complication and was discharged home.ConclusionsDengue fever is a common tropical infection. Recognizing serious complications such as psoas haematoma presenting as simple complaints such as back pain and inguinal pain are important to prevent mortality.

Pelvic muscle size and myosteatosis: Relationship with age, gender, and obesity

Purpose:To evaluate interreader performance in the measurement of the cross-sectional area and myosteatosis of pelvic skeletal muscles using fat quantification magnetic resonance imaging (MRI) and correlate with patient anthropomorphic characteristics.Materials and Methods:A Health Insurance Portability and Accountability Act–compliant retrospective cross-sectional study was performed. Between January and April 2016, 61 patients (26 males and 35 females) underwent a lumbosacral plexus 3T MRI with a modified three-dimensional spoiled gradient echo sequence dedicated to fat quantification (mDixon Quant; Philips Healthcare). Two independent reviewers outlined muscle cross-sectional area on axial images using a freehand region of interest tool and documented proton-density fat fraction (FF) and muscle area (cm2) of the psoas, gluteus medius, gluteus maximus, and rectus femoris muscles on each side. Interreader agreement was assessed by intraclass correlation coefficient (ICC), and correlation between the measurements and subject's age, gender, and body mass index (BMI) was assessed using multiple linear regression analysis.Results:Excellent interreader agreement was obtained (ICC ≥0.74) for all muscle groups except for the left gluteus medius area and right psoas FF which showed good agreement (0.65 and 0.61, respectively). Statistically significant (P ≤ 0.05) positive correlation was seen between the gluteal muscle FF and area with BMI, and rectus muscle FF with age and BMI. Statistically significant negative correlation between the rectus femoris area and age was also observed.Conclusion:Fat quantification MRI is a highly reproducible imaging technique for the assessment of myosteatosis and muscle size. Intramuscular FF and cross-sectional area were correlated with age and BMI across multiple muscle groups.

Absceso del músculo psoas iliaco como causa de lumbociatalgia

Introducción: Se presenta el reporte de un caso clínico de Lumbociatica Aguda cuya etiología se correspondió con un Absceso en el músculo psoas iliaco izquierdo, evidenciado como la presencia de una colección de pus en el compartimiento del músculo iliopsoas, entidad relativamente poco frecuente y con una presentación clínica inespecífica y larvada. El caso fue asistido en el Hospital Provincial General Latacunga en el año 2016. Las etiologías más frecuentes de la lumbociatalgia son las discopatías y hernias de disco, siendo el absceso del psoas una entidad poco frecuente, pero al ser los procesos infecciosos una causal de lumbalgia y lumbociatica, en el orden diagnóstico siempre debe ser considerada esta posibilidad.&#x0D; Objetivo: Describir un caso clínico de Absceso del músculo Psoas Iliaco como causa de lumbociatalgia.&#x0D; Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico.&#x0D; Resultados: Se reporta un caso atendido en el Hospital Provincial General de Latacunga, se trata de un paciente de 31 años con antecedentes de Pielonefritis aguda a los 19 años que acude por lumbociatalgia y se comprueba la presencia de un absceso del músculo psoas ilíaco como etiología del síntoma. El diagnóstico se realizó mediante exámenes de laboratorio, resonancia magnética nuclear de columna lumbar y ecografía abdominal. La conducta terapéutica se basó en antibioticoterapia de amplio espectro y la realización de un procedimiento mínimamente invasivo: drenaje del absceso por vía percutánea mediante la técnica de Seldinger guiado por ultrasonido. Los resultados fueron muy satisfactorios, con un seguimiento posterior durante un año.&#x0D; Conclusiones: Se debe considerar el diagnóstico etiológico infeccioso ante una lumbociatalgia aguda, y entre sus variedades, tener en cuenta el absceso del músculo psoas ilíaco, aunque las discopatías y hernias del disco, le superen en frecuencia.

Extensive paraspinal tuberculosis masquerading malignant tumor in an elderly male

Paraspinal tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis, and in rare cases, these lesions can mimic malignant lesions. We report a case of an elderly man where imaging showed extensive left paraspinal lesion which was mimicking malignant neoplasm. The patient underwent L3–L4 unilateral partial laminotomy, there was grayish, relatively avascular lesion in the left paraspinal region, involving the left psoas muscle and going into the neural foramina, and a subtotal resection of the lesion could be performed. However, after biopsy, it turned out to be tuberculoma, and the patient was on antitubercular therapy and doing well. The present case illustrates that extensive involvement of the paraspinal soft tissue and adjacent bony structures on imaging in tuberculosis can mimic malignant tumors. Conservative surgical excision will help in preserving the bony elements and in establishing the diagnosis.

Multidetector Computed Tomographic Characterization of a Rare Retroperitoneal Mass in the Left Psoas Compartment

AbstractWe discuss a case of a rare, large, left-sided retroperitoneal mass that presented a diagnostic difficulty in characterization both radiologically and pathologically. We analyze the imaging findings in a step-by-step manner to understand its structure of origin, components, and tissue characterization. Intraoperative images are correlated with multidetector computed tomographic (CT) scan images to demonstrate spatial orientation. A discussion of the pathological findings, and conclusions are made. This discussion highlights the methodology by which radiologic diagnosis is made on multidetector CT scans.

Relation of lumbar sympathetic chain to the open corridor of retroperitoneal oblique approach to lumbar spine: an MRI study.

Retroperitoneal oblique approach to lumbar spine used surgical corridor between psoas muscle and aorta for exposure to anterior part of lumbar spine. Lumbar sympathetic chain (LSC) runs in the corridor to make it a structure at risk of injury. Does LSC relationship with surgical corridor for minimally invasive retroperitoneal anterolateral oblique approach change in different intervertebral disc level? Left LSC was identified in axial magnetic resonance imaging images at L2-3, L3-4 and L4-5 intervertebral disc levels of 144 patients. Distances between LSC and left psoas muscle and aorta were recorded. Mean age of the patients was 62.3years. LSC was identifiable in 90.9% of levels. Distance between LSC and psoas muscle at L2-3, L3-4 and L4-5 was 4.0mm, 4.7mm and 5.2mm. Statistical difference was found between L2-3 and L4-5 level (p = 0.006). Distance between LSC and aorta at each level was 12.4mm, 12.3mm and 10.6mm without statistical difference. In non-scoliosis group distance between LSC and psoas muscle at each level was 3.1mm, 3.3mm and 4.0mm. Statistical difference was found between L2-3 and L4-5 level (p = 0.012) and between L3-4 and L4-5 level (p = 0.041). Distance between LSC and aorta at each level was 11.9mm, 11.4mm and 10.2mm. Statistical difference was found between L2-3 and L4-5 disc level (p = 0.039). LSC moves away from psoas muscle and becomes closer to aorta in L4-5 disc level. These slides can be retrieved under Electronic Supplementary Material.

Opportunistic Measurement of Skeletal Muscle Size and Muscle Attenuation on Computed Tomography Predicts 1-Year Mortality in Medicare Patients

Opportunistic assessment of sarcopenia on CT examinations is becoming increasingly common. This study aimed to determine relationships between CT-measured skeletal muscle size and attenuation with 1-year risk of mortality in older adults enrolled in a Medicare Shared Savings Program (MSSP). Relationships between skeletal muscle metrics and all-cause mortality were determined in 436 participants (52% women, mean age 75 years) who had abdominopelvic CT examinations. On CT images, skeletal muscles were segmented at the level of L3 using two methods: (a) all muscles with a threshold of -29 to +150 Hounsfield units (HU), using a dedicated segmentation software, (b) left psoas muscle using a free-hand region of interest tool on a clinical workstation. Muscle cross-sectional area (CSA) and muscle attenuation were measured. Cox regression models were fit to determine the associations between muscle metrics and mortality, adjusting for age, sex, race, smoking status, cancer diagnosis, and Charlson comorbidity index. Within 1 year of follow-up, 20.6% (90/436) participants died. In the fully-adjusted model, higher muscle index and muscle attenuation were associated with lower risk of mortality. A one-unit standard deviation (SD) increase was associated with a HR = 0.69 (95% CI = 0.49, 0.96; p = .03) for total muscle index, HR = 0.67 (95% CI = 0.49, 0.90; p < .01) for psoas muscle index, HR = 0.54 (95% CI = 0.40, 0.74; p < .01) for total muscle attenuation, and HR = 0.79 (95% CI = 0.66, 0.95; p = .01) for psoas muscle attenuation. In older adults, higher skeletal muscle index and muscle attenuation on abdominopelvic CT examinations were associated with better survival, after adjusting for multiple risk factors.

Pelvic Actinomycosis. Autposy Finding

Background: Actinomycosis is a suppurative and granulomatous chronic infectious disease due to a gram positive, non-spore-forming, anaerobic bacteria, non-acid-alcohol resistant bacteria The organisms are indigenous in the oral cavity, pharynx, gastrointestinal tract, and genital tracts. There are at least 6 species that can affect the human, Actinomyces israelii is the most frequent. Methods & Materials: Autopsy is performed for alleged medical non-compliance to a 41-year-old woman with Paranoid Schizophrenia postpartum in treatment at the admission to the hospital she had normal vital parameters and standard physical examination, indirect anamnesis to parents reporting a different behavior in the last days. At necropsy, enlarged lungs are seen, with a yellowish, thick secretion. Abdomen hepatomegaly. Pelvic: left psoas with multiple abscesses. Is evidenced hypogastric plastron, involving uterus, small intestine, large intestine and bladder. To cut thick purulent brown material. Fallopian tubes and ovaries were not identified. Intrauterine contraceptive device is present. Pathologic diagnosis was: abscessed endometritis secondary to Actinomyces israelii with extension to cervix, appendages and pelvic organs with adherent plastron. Psoas abscesses with venous thrombosis. Pericarditis and lymphoplasmacytic myocarditis. Bronchopneumonia. Steatohepatitis with hemophagocytes. Disseminated intravascular coagulation. Cause of Death Organic Dysfunction Multiple-Shock Septic- abdominal-pelvic infection Endometritis by Actinomyces israelii. Results: Pelvic actinomycosis is an uncommon, opportunistic infection with a non-specific clinical course. It must be considered as a differential diagnosis in infiltrative processes suggestive of pelvic neoplasms. It presents a good evolution in the early diagnosis, with a response to beta-lactams. Schizophrenic patients show higher rates of serious infections than in the general population, since they are not aware of pain, which has an impact on morbidity and mortality, so it is suggested to perform interdisciplinary work and include in the medical controls the areas of hygiene, diet, activities, treatment of comorbid diseases and vaccines. Conclusion: The psychiatric pathology of the patient, caused that the evolution of the pathology is torpid in the absence of a clinical setting that guides tutors and doctors to the diagnosis.

A difficult situation \u2013 balancing critical anticoagulation versus the risk of permanent neurologic deficit: a case report

BackgroundAnticoagulation is the mainstay of treatment for pulmonary embolism. However, if bleeding unfortunately occurs, the risks and benefits of anticoagulation present a challenge. Management of one hemorrhagic complication, retroperitoneal hematoma, is rare, difficult, and controversial.Case presentationA 73-year-old white man presented with left lower extremity swelling and dyspnea. He was tachycardic, hypertensive, and demonstrated poor oxygen saturation of 81% on ambient air. A computed tomography angiogram revealed a saddle pulmonary embolus. Tissue plasminogen activator was administered and he was started on a heparin infusion. He was eventually transitioned to enoxaparin. On the day of discharge, however, he had sudden onset of right leg numbness and weakness below his hip. A computed tomography of his head was not concerning for stroke, and neurology was consulted. Neurology was concerned for spinal cord infarction versus hematoma and recommended magnetic resonance imaging of his thoracic and lumbar spine. The magnetic resonance imaging revealed a left psoas hematoma. A computed tomography scan of his pelvis also showed a right psoas and iliacus hematoma. He was transitioned to a low intensity heparin infusion. The following day his left leg exhibited similar symptoms. There was concern of progressive and irreversible nerve damage due to compression if the hematomas were not drained. Interventional radiology was consulted for drainage. The heparin infusion was paused, drainage was performed, and the heparin infusion was reinitiated 6 hours following the procedure by interventional radiology. His blood counts and neurologic examination stabilized and eventually improved. He was discharged home on a novel anticoagulant.ConclusionsManagement of a retroperitoneal hematoma can commence with recognition of the warning signs of bleeding and neurological impairment, and consulting the appropriate services in case the need for intervention arises. A conservative approach of volume resuscitation and blood transfusion can be used initially, with the need for pausing or reversing anticoagulation being assessed on an individual basis with expert consultation. If intervention becomes necessary, other interventional radiology-based modalities can be used to identify and stop the bleeding source, and interventional radiology-guided drainage can be performed to decrease the hematoma burden and relieve neurological symptoms.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. Retrospective cohort. American College of Surgeons Level I trauma center. One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.