Lumbar Lesions Research Articles

Identification and Incidence of Spina Bifida during Gestation and its Pregnancy Outcomes

Aim: To identify the incidence of spina bifida during gestation and its pregnancy outcomes. Study design: Cohort study Place and duration of study: Department of Radiology, Chandka Medical College Hospital, Larkana from 1st October 2020 to 30th September 2022 Methodology: One thousand pregnant women who were screened for the identification of spina bifida. Doppler based ultrasonography was performed in each patient. The fetus body was examined during sonography Doppler between 18-24 weeks. The body of the fetus was focused and visualized longitudinally in midsagittal section. Spinal cord was traced from neck to sacral, cervical vertebra and thorax. A tram track appearance was observed. Spinal nerve positioning was also observed. In spina bifida nerve tethering was seen. The primary outcomes in reference to baby weight and maturity were recorded while secondary outcomes of the fetuses in terms of any disability were followed up to 12 months of age. Results: The mean age of the women was 25.6±5.6 years. The incidence of spina bifida was 1.1%. Within the primary outcomes observed birth weight ranged within 3.1-3.5kg. Around 81.81% cases were born full term while 18.18 were premature. On 06 months’ follow-up of the spina bifida cases it was observed that 45.45% of new born suffered from skin problems as sores, calluses or and blisters while 36.36% had hydrocephalus with excessive CSF which needed monitoring. Mobility issue and disability was observed in 27.27% cases. Conclusion: Spina bifida cases are identified successfully within gestational period. Prematurity can be significantly noticed in spina bifida cases. The lumbosacral and lumbar lesions are most common as well as skin conditions and hydrocephalus. Key words: Incidence, Spina bifida, Gestation, Outcome

Relationship between sex and clinical and imaging features of early axial spondyloarthritis: results from a 48 month follow-up (Italian arm of the SPondyloArthritis Caught Early (SPACE) study)

Objectives To assess the association between sex and clinical and disease activity indices, and X-rays and magnetic resonance imaging (MRI) features, in early-stage axial spondyloarthritis (axSpA). Method Baseline data analysis was conducted on the Italian SPACE cohort, including patients with chronic back pain (duration ≥ 3 months and ≤ 2 years; onset < 45 years). Patients underwent MRI and X-rays of the sacroiliac joints (SIJs) to establish the diagnosis of axSpA, according to Assessment of SpondyloArthritis international Society criteria and physician’s judgement. Clinical features, disease activity and functional indices, and images were collected at baseline and yearly during 48 months. Spinal and SIJ X-rays and MRI images were scored by two readers following Spondyloarthritis Research Consortium of Canada (SPARCC), modified Stoke Ankylosing Spondylitis Spinal Score, and modified New York criteria. Characteristics of axSpA patients according to sex (male/female) were compared over time using descriptive statistics. Results Ninety-one patients had axSpA (83.5% non-radiographic; 16.5% radiographic); 47.3% were male. Males were younger, with shorter duration of axial symptoms, and more frequently had HLA-B27 positivity, radiographic sacroiliitis with a bilateral/symmetric pattern, and more signs of spondylitis. Females more frequently showed peripheral/entheseal involvement and the non-radiographic phenotype. Males showed increased pelvic/spinal radiographic progression and more often had active sacroiliitis on MRI. Although the frequency of inflammatory corner lesions did not differ between males and females, localization varied, with more cervical/thoracic MRI-spine lesions in females and more lumbar lesions in males. We observed a significant downward trend of SPARCC SIJ/spine scores in all patients, irrespective of sex. More fat lesions were observed on MRI-spine in females and on MRI-SIJ in males. Conclusion Sex was associated with distinct axSpA features: females showed low-grade radiographic sacroiliitis and spinal progression, and a higher prevalence of cervical and thoracic spine MRI signs.

Oblique Lumbar Interbody Fusion with Selective Biportal Endoscopic Posterior Decompression for Multilevel Lumbar Degenerative Diseases.

Oblique lumbar interbody fusion is a minimally invasive procedure for treating degenerative lumbar disease. Its advantages include correcting coronal and sagittal spinal alignment and indirect neural decompression. However, achieving a successful outcome is limited in some patients who need direct decompression for central canal lesions including hard stenotic lesions (endplate or facet articular osteophytes and ossification of posterior longitudinal ligaments) and sequestration of the disk. Biportal endoscopic spinal surgery is a minimally invasive technique, which directly decompresses the lesion. By taking advantage of two procedures, in a longlevel lumbar lesion, alignment correction and direct decompression can be both achieved. Herein, the authors introduce multilevel lumbar fusion through oblique lumbar interbody fusion and selective direct decompression through biportal endoscopic spinal surgery and discuss the surgical indications, surgical pitfalls, and recommendations for application. Consequently, it is regarded as a minimally invasive interbody fusion method for patients with multilevel lumbar degenerative degeneration.

First Clinical Report of the Intraoperative Macro- and Micro-Photodiagnosis and Photodynamic Therapy Using Talaporfin Sodium for a Patient with Disseminated Lumbar Medulloblastoma.

Photodiagnosis (PD) and photodynamic therapy (PDT) using the second-generation photosensitizer talaporfin sodium together with an exciting laser for primary intracranial malignant tumors is well recognized in Japan, and many medical institutions are introducing this new therapeutic option. In particular, intraoperative PDT using talaporfin sodium for infiltrating tumor cells in the cavity walls after the resection of malignant glioma is now covered by health insurance after receiving governmental approvement, and this method has been recommended in therapeutic guidelines for primary malignant brain tumors in Japan. On the other hand, experimental and clinical studies on the development of novel therapeutic strategies for malignant spinal cord tumors have not been reported to date, although their histological features are almost identical to those of intracranial malignant tumors. Therefore, the clinical outcomes of malignant spinal cord tumors have been less favorable than those of malignant brain tumors. In this report, we performed the PD and PDT using talaporfin sodium on a patient with a metastatic lumbar lesion that was detected on magnetic resonance image (MRI) 50 months after the resection of cerebellar medulloblastoma who presented with lumbago and sciatica. We were able to detect the target lesion in the conus medullaris using a surgical microscope, and detected the disseminated medulloblastoma cells floating in the cerebrospinal fluid using a compact fluorescence microscope. Furthermore, we performed PDT to the resected lumbar lesion with the adjuvant platinum-based chemotherapy, and the patient survived a meaningful life for more than 2 years after the lumbar surgery. This report describes the first case of a human patient in whom the efficacy of PD and PDT was demonstrated for a malignant spinal cord tumor.

Brucella cultures characteristics, clinical characteristics, and infection biomarkers of human Brucellosis

ObjectiveAim to investigate the brucella culture characteristics, diagnosis methods, and clinical characteristics, to provide the laboratory with diagnostic methods and prevention and treatment for brucellosis. MethodsData of 328 cases of brucellosis from 2012 to 2022 was analyzed, retrospectively. The bacterial culture characteristics, the clinical diagnostic methods, and the complications were analyzed respectively. The infection biomarkers of the brucellosis were analyzed by Receiver operating characteristic curve ROC. ResultsAmong the 328 brucellosis, 78.96 % of cases were men, the median age of the patients was (45.21±13.49) years and the annual incidence in our region was 67/100 000 per year. The diagnostic methods included pathogenic bacteria culture, serological diagnosis, and suspect case were 24.39 %, 47.56 %, and 28.05 %, respectively, sensitivity of combined detection Standard agglutination test (SAT) and the Rose Bengal test (RBT) is 96.2 %. In our work, 80 cases of brucellosis were diagnosed by a bacterial culture which were been identified as Brucella melitensis, blood culture was the main method (78.75 %) and the average positive alarm time was 80.74 (21.6–129) h and all of them were detected in aerobic bottles, followed by synovial fluid, bone marrow, lumbar spine, and joint tissue, puncture fluid and ascites culture which were 6.25 %, 3.75 %, 5.00 %, 5.00 % and 1.25 % respectively. The brucellosis with complications was lumbar spine lesions at 41.46 % cervical spine lesions at 4.60 % and knee joint lesions at 12.8 % and another osteoarthritis. The in-hospital mortality rate of the patients was 0.91 % and all of them were meningitis patients. ROC analysis indicated CRP had high sensitivity and specificity for brucellosis, and when CRP was 1.23mg/ml, the sensitivity and specificity were 0.727 and 0.718 respectively, and the U test also indicated CRP had a significant difference, Z=5.054, p <0.001. ConclusionsBrucellosis is frequently morbidity in 40 + age men, which has been diagnosed by aerobic blood culture, generally bacterial culture, RBT and SAT, epidemiological, and commonly with complications of spine and arthropathy.

The Videourodynamic Characteristics of Patients with Chronic Spinal Cord Injury with Different Injury Levels and Bladder Conditions

Purpose: This study aimed to analyze the association between bladder conditions and Neurogenic lower urinary tract dysfunction (NLUTD) characteristics in patients with spinal cord injury (SCI) with different injury levels using a videourodynamic study (VUDS). Materials and Methods: A single-center, retrospective review of the VUDS database on patients with NLUTD and chronic SCI from 1997 to 2020. A total of 507 patients were enrolled. All patients had a comprehensive chart review, including the injury level, period from diagnosis to VUDS, and VUDS characteristics. Results: The mean age and duration from SCI diagnosis to VUDS were 44.2 ± 15.7 years and 81.8 ± 89.0 months. Detrusor overactivity (DO) was observed in 67.7% of patients and detrusor underactivity (DU) in 26.0%. Bladder outlet obstruction was noted in 78.3% of patients, including detrusor sphincter dyssynergia (DSD) in 53.3% and bladder neck dysfunction in 25.0%. DO and DSD were more commonly observed in patients with suprasacral lesions (P = 0.000 and P = 0.000, respectively), whereas DU had a higher prevalence in patients with lumbar or sacral lesions (P = 0.000). No statistically significant difference was observed in the prevalence of vesicoureteral reflux among different SCI levels. Bladder sensation parameters were more preserved in patients with cervical SCI than in those with lumbar SCI; however, no significant difference in bladder compliance was observed among patients with different SCI levels. Conclusion: The VUDS in patients with SCI revealed a high prevalence of DO, DU, and DSD, which varied among different injury levels. A precise VUDS is necessary for deciding bladder management for patients with SCI and voiding dysfunction.

Lumbar Fusion including Sacroiliac Joint Fixation Increases the Stress and Angular Motion at the Hip Joint: A Finite Element Study.

Adult spinal fusion surgery improves lumbar alignment and patient satisfaction. Adult spinal deformity surgery improves saggital balance not only lumbar lesion, but also at hip joint coverage. It was expected that hip joint coverage rate was improved and joint stress decreased. However, it was reported that adjacent joint disease at hip joint was induced by adult spinal fusion surgery including sacroiliac joint fixation on an X-ray study. The mechanism is still unclear. We aimed to investigate the association between lumbosacral fusion including sacroiliac joint fixation and contact stress of the hip joint. A 40-year-old woman with intact lumbar vertebrae underwent computed tomography. A three-dimensional nonlinear finite element model was constructed from the L4 vertebra to the femoral bone with triangular shell elements (thickness, 2 mm; size, 3 mm) for the cortical bone's outer surface and 2-mm (lumbar spine) or 3-mm (femoral bone) tetrahedral solid elements for the remaining bone. We constructed the following four models: a non-fusion model (NF), a L4-5 fusion model (L5F), a L4-S1 fusion model (S1F), and a L4-S2 alar iliac screw fixation model (S2F). A compressive load of 400 N was applied vertically to the L4 vertebra and a 10-Nm bending moment was additionally applied to the L4 vertebra to stimulate flexion, extension, left lateral bending, and axial rotation. Each model's hip joint's von Mises stress and angular motion were analyzed. The hip joint's angular motion in NF, L5F, S1F, and S2F gradually increased; the S2F model presented the greatest angular motion. The average and maximum contact stress of the hip joint was the highest in the S2F model. Thus, lumbosacral fusion surgery with sacroiliac joint fixation placed added stress on the hip joint. We propose that this was a consequence of adjacent joint spinopelvic fixation. Lumbar-to-pelvic fixation increases the angular motion and stress at the hip joint.

NIMG-89. DISSEMINATED SPINAL METASTASES FROM A PITUITARY CARCINOMA

Abstract Pituitary carcinomas are rare malignant neoplasms and rarely result in a solitary spinal metastasis. In this report we describe a case of pituitary carcinoma that metastasized to the spinal canal and the nerve roots at numerous spinal levels, mimicking neurofibromatosis of the spine. This patient is a 72 year old right-handed female with past medical history of pituitary adenoma which was resected 5 years prior and stable on imaging. At presentation, patient was seen for right sciatica, and an MRI showed multiple enhancing intradural extramedullary lesions mainly in the lumbar spine, felt to represent nerve sheath tumors, neurofibromas. She underwent genetic testing, but NF1, NF2, SMARC1B, SPRED1, LTRZ1 were not found to have a mutation. Over a 3 year period, she had progression of her spinal tumors. The pituitary lesion remained stable in appearance. She underwent resection of multiple lumbar lesions and pathology was consistent with pituitary carcinoma.Patient tolerated up to almost 11 full cycles of temozolomide before it was put on hold due to significant deconditioning and lethargy. Imaging revealed a partial response of the spinal cord metastases. This is an unusual presentation for metastatic pituitary carcinoma and delay in diagnosis resulted in significant morbidity.

Incidence of spinal cord injuries in Germany

PurposeThe goal of this study was to provide recent data on incidence of spinal cord injuries (SCI) in Germany.MethodsThe source of information was data collected via the mandatory submission of ICD-10 GM Codes by German public hospitals after patient discharge. Data from 2013 to 2020 were retrieved from the databases of the Federal Bureau of Statistics. ICD-10 Codes for acute SCI were identified. Statistical analysis was performed using Jamovi and Excel.ResultsA total of 10,360 patients were reported, of whom 58.7% suffered from a cervical, 30.8% a thoracic and 10.4% a lumbar lesion. Two peaks in incidence were observed at approximately 30 and 70 years old. A population-size-adjusted overall incidence of 15.73 (SD 0.77) per million per year was calculated. We calculated the incidences in several subpopulations and discovered significantly higher incidences among males and among those over the age of 60. We discovered that differences in age groups mainly concerned injuries of the upper spine, with the incidence in the lumbar spine being similar among age groups. In addition, we found that while the probability of suffering from SCI increases with age, the relative risk of suffering from a complete injury decreases.ConclusionsThis study closes a long-lasting gap in epidemiological data regarding SCI in Germany, specifically by updating the incidence rates. We found that incidence depends on age, gender and type of lesion. We also provide some new angles for future research, especially considering the relative reduction in complete injuries among the elderly.

Assessment of Intraoperative Spinal Angiography via the Popliteal Artery for Spinal Vascular Diseases

Intraoperative spinal angiography via the popliteal artery for patients in the prone position has been reported only twice in 4 patients. This study aimed to clarify the safety precautions to be taken with this technique in a larger patient cohort. Seven patients with spinal vascular disorders underwent intraoperative spinal angiography in the prone position via the popliteal artery. Ultrasound was used to evaluate the neurovascular anatomy in the popliteal fossa and guide the arterial puncture. Patient characteristics, features of angiography devices, puncture attempts, and angiography-related complications, such as hematoma formation and injury to the neurovascular bundle, were analyzed. The average number of arterial puncture attempts was 1.3 times (range: 1-2). Sheaths (4 and 4.5 Fr) with different ineffective lengths were used. In 1 case, a 4.5-Fr sheath was replaced with a 4-Fr sheath with a shorter noneffective length as the length of the catheter limited access to the target. Catheters with Type-JB2 tip shapes were used for craniocervical junction lesions, and those with Type-KAGAWA tip shapes were used for thoracic and lumbar spinal lesions. No puncture site complications were observed in any patient. Intraoperative spinal angiography via the popliteal artery was an effective tool in surgeries for spinal vascular diseases. The introduction of the ultrasound enabled atraumatic puncture of the popliteal artery. Spinal targets above T5 to T6 may be inaccessible from the popliteal fossa when using a 100-cm-long catheter.

Dual-Rod Instrumentation Via the Anterior Approach for Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis

Background: Posterior spinal fusion with pedicle screw instrumentation is currently the standard technique for spinal surgery. However, the anterior approach remains useful for thoracolumbar and lumbar (TL/L) lesions, such as in adolescent idiopathic scoliosis (AIS) 1–4 and spinal injuries 5,6 . We previously documented that long-term radiographic findings and clinical measures were satisfactory in patients with TL/L AIS treated with anterior dual-rod instrumentation 1 . Description: This surgical technique is indicated for single TL/L (Lenke 5) curves and is performed with use of extrapleural retroperitoneal approaches. The extrapleural cavity is connected to the retroperitoneal space by diaphragmatic transection. The lateral aspect of the vertebral bodies is exposed by retracting the psoas major muscle posteriorly from the intervertebral discs. Segmental vascular bundles are divided with coagulation and/or ligation. Care should be taken to reflect the psoas in its entirety and avoid an intramuscular approach to prevent bleeding injury to nerves, including the femoral, ilioinguinal, and genitofemoral nerves, as well as ureteral injury. After the intervertebral discs and cartilage plates are removed to the vertebral end plates, 2 screws are inserted in each vertebral body through a vertebral staple 1,4 . The anterior rod is then placed in the screw heads and rotated anteriorly, providing 3-dimensional correction of kyphotic deformities with lordosis production 1,4 . After the posterior rod is applied in the same manner as the anterior rod, compression forces are applied between the screws to correct scoliosis 1,4 . The compression force is first applied to the posterior rod so that kyphosis can be corrected more effectively 1,4 . Alternatives: Posterior pedicle screw instrumentation techniques are widely utilized for TL/L AIS curve correction. However, anterior techniques have frequently also been applied to the curve. Dwyer et al. 7 first reported the use of anterior spinal fusion (ASF) with a single braided cable connecting vertebral screws for the treatment of TL/L AIS, and Zielke et al. 8 modified that procedure by replacing the cable with a threaded rod. Although these instrumentation techniques and other single anterior rod techniques such as the Texas Scottish Rite Hospital System effectively correct scoliosis in the coronal plane and improve vertebral derotation 1,9 , poor sagittal and rotational plane deformity correction, implant weakness, and high incidence of pseudarthrosis remain unresolved issues 1 . Rationale: The fundamental advantages of the anterior approach in dual-rod instrumentation are the ability to achieve 3-dimensional correction with extremely low rates of pseudarthrosis and implant failure 1,10–12 . Furthermore, the fusion is expected to include fewer motion segments than with posterior systems (usually 1 level less distally and proximally). However, low skeletal maturity and a TL/L to thoracic Cobb ratio of &lt;1.25 appeared to be important factors for postoperative curve progression of the thoracic coronal deformity following ASF for the treatment of Lenke 5 curves 1,13 . In addition, subjacent disc wedging may occur when the subjacent disc is nearly parallel before surgery 1,14 . Expected Outcomes: The described technique is expected to provide 3-dimensional spinal correction. In a previous study, 30 patients with Lenke 5 AIS were followed for a mean of 17 years 1 . The mean TL/L Cobb angle correction rate and correction loss were 79.8% and 3.4°, respectively, at the time of the latest follow-up 1 . The average percent of predicted forced vital capacity and of forced expiratory volume in 1 second were 91.8% and 81.8%, respectively 1 . The average total score on the Scoliosis Research Society-30 outcome instrument was 4.21. No instrumentation failure, pseudarthrosis, or clinically relevant neurovascular complications were observed 1 . Important Tips: This technique is applicable to Lenke 5 AIS curves. However, the anterior approach can also be utilized for other TL/L lesions.The anterior procedure is accomplished via extrapleural retroperitoneal approaches with diaphragmatic transection.Care should be taken to reflect the psoas in its entirety and avoid an intramuscular approach to prevent bleeding and nerve and ureteral injuries. Acronyms &amp; Abbreviations: SRS-30 = Scoliosis Research Society-30

OA21 Ankylosing Spondylitis management with Secukinumab but related Inflammatory bowel disease phenomenon

Introduction/BackgroundAnkylosing spondylitis is a HLA B27 associated inflammatory spondyloarthropathy. It can be a debilitating disease affecting mobility and quality of life, therefore, effective symptom and disease control is crucial and consists of pharmacological, including biologics, and non-pharmacological modalities. Until recently, pharmacological treatment options for spinal inflammatory disease control was limited to mainly NSAIDs. Development of biological drugs such as TNF inhibitors and selective Interleukin-17 inhibitors have revolutionized the management especially for patients refractory to conventional treatment. However, use of these novel biologics can come at a cost of side effects including risk of infection and exacerbation of underlying inflammatory conditions.Description/MethodThis 60-year-old Afro-Caribbean female was referred to Rheumatology department with 1-year history of non-radiating lower back pain, alternating buttock pain and morning stiffness. On spinal and sacral MRI, she was found to have multiple thoracic and lumbar spine Romanus lesions and active sacroiliitis and had bilateral grade 2-3 sacroiliitis on plain x-rays of the sacroiliac joints. She also had a raised ESR. There was no peripheral joint involvement, psoriasis, inflammatory eye disease or previous history of inflammatory bowel disease. Her HLA-B27 was negative. Subsequently, she was diagnosed with AS. Previously, she had tried NSAIDs via GP including Diclofenac and Naproxen. She was started on Etoricoxib.Other issues included spinal canal stenosis at L4/L5 due to disc degeneration, facet joint and ligamentum flavum hypertrophy.For non-pharmacological management she was under the care of physiotherapy team who advised for regular physiotherapy, acupuncture and hydrotherapy.On follow up, she did not derive benefit from the Etoricoxib (BASDAI 8.5 and VAS 75), consequently underwent pre-biologic work up. After these were confirmed as normal she was started on Secukinumab 150mg monthly injections (after weekly loading) as per the patient’s preferred biologic choice.After initiating Secukinumab, her AS improved significantly (reductions in BASDAI to 2.5 and VAS 30). However, after six months, she developed gastrointestinal symptoms with mainly bloating, intermittent diarrhoea and epigastric abdominal pain. She then developed gradual unintentional weight loss.Under gastroenterologist care, she had extensive diagnostic workup including upper GI endoscopy and colonoscopy (with biopsies), CT-TAP, MRI small bowel and faecal elastase, all of which were normal. However, her faecal calprotectin was high at 130mg/kg (normal range 0-51mg/kg).Secukinumab was continued given her spinal disease improvement, however, after 18 months of therapy and ongoing gastrointestinal symptoms, Secukinumab was stopped in May-2021. Within weeks of stopping her GI symptoms completely resolved.Discussion/ResultsUse of Secukinumab has been licensed for rheumatological diseases such as psoriatic arthritis, AS and plaque psoriasis. It works by antagonizing interleukin 17, which is a pro-inflammatory cytokine. We started Secukinumab in this patient as per patient choice.Considering she developed gastrointestinal symptoms it was important to rule out IBD as Secukinumab has been associated with exacerbating underlying IBD or even inducing new cases. For this purpose, part of our workup included faecal calprotectin, colonoscopy and MRI to rule out IBD.We recommend for patient who are being treated with Secukinumab that if they develop gastrointestinal symptoms it is important to consider iatrogenic IBD. It is recommended in such cases to discontinue Secukinumab and consider alternative biologics with a different mode of action.It is still not clear what risk factors may help to predict which patients treated with Secukinumab for AS (or other seronegative disorders) could develop iatrogenic IBD. It is also unclear why the epiphenomenon of IBD can be exacerbated by IL17 inhibition when it is clear that such cytokine targeting in AS, psoriasis and psoriatic arthritis is evidently beneficial. Is there a role in pre-biologic screening and monitoring during treatment using faecal calprotectin?Key learning points/ConclusionThough Secukinumab is an effective biologic in the management of symptoms and disease control in Ankylosing spondylitis it can be associated with either flare or development of Inflammatory Bowel Disease phenomenon.

Surgical Management of Aggressive Vertebral Hemangioma

Background: This study includes management of aggressive vertebral hemangioma (VH). VH is the most common primary tumor affecting the vertebral column. In 0.9–1.2% of patients, VH can become symptomatic and is termed as “aggressive vertebral hemangiomas.” They usually require surgery along with adjuvant modalities. Due to its relatively low incidence, there is sparse reporting in the open literature and lack of universal consensus on treatment protocol. We would like to present our institutional experience in managing aggressive VH by surgery along with adjuvant modalities and a comprehensive review of the literature. Materials and Methods: A retrospective review of records of VH cases managed surgically in the past 3 years at our institute was done. All the relevant records and imaging of the patients were retrieved. Results: Five patients were included in the study. All were male with four dorsal and one lumbar lesion. All were treated with surgery along with an adjuvant therapy. Selective arterial embolization was used in one patient, alcohol ablation in three, and vertebroplasty in one. Only one patient had gross total resection, and others had only decompression. Fixation was done in all. All showed good clinical improvement without any complications, except in one. Conclusion: Aggressive VH often requires surgery. Currently, a decompression surgery is preferred due to less morbidity with good clinical outcomes. Various adjuvant therapies have been described in literature to be used perioperatively; yet there is no universal consensus on a standard protocol. Each of them has its own advantages and limitations and thus needs to be carefully selected on an individual basis. Alcohol ablation is an established adjuvant modality, but has to be used with caution.

Comparison of Ray Tracing and Monte Carlo Calculation Algorithms for Spine Lesions Treated With CyberKnife.

PurposeThis study attempts to evaluate Ray Tracing (RT) and Monte Carlo (MC) algorithms for CyberKnife treatments of spine lesions and determine whether the MC algorithm is necessary for all spine treatment and compare the RT algorithm and MC algorithm at various spine lesion sites.MethodsThe CyberKnife is used for stereotactic body radiotherapy for lesions in the cervical spine (30), thoracic spine (50), lumbar spine (30), and sacral spine (15). Dose was calculated using RT and MC algorithms for patients planned with the same beam angles and monitor units. Dose-volume histograms of the target and selected critical structures are evaluated.ResultsThe average target coverage of prescribed dose with MC algorithms was 94.80%, 88.47%, 92.52%, and 93.41%, respectively, in cervical, thoracic, lumbar, and sacral spine. For the thoracic spine, the RT algorithm significantly overestimates the percentage volume of the target covered by the prescribed dose, as well as overestimates doses to organs at risk in most cases, including lung, spinal cord, and esophagus. For cervical, lumbar, and sacral spine, the differences of the target coverage of prescription dose were generally less than 3% between the RT and MC algorithms. The differences of doses to organs at risk varied with lesion sites and surrounding organs.ConclusionsIn the thoracic spine lesions with beams through air cavities, RT algorithm should be limited and verified with MC algorithm, but the RT algorithm is adequate for treatment of cervical, lumbar, and sacral spine lesions without or with a small amount of beams passing through the lungs.

Judgement of the Clinical Value of Spiral CT Three-Dimensional Reconstruction in the Diagnosis of Lumbar Degenerative Osteoporosis.

With the aging of the population, there are more and more degenerative diseases of the lumbar spine that accompany osteoporosis. Lumbar degenerative osteoporosis has also become fragile and high in incidence, which has also attracted the attention of experts and scientists in related fields. Degeneration of the lumbar spine often causes pain in the waist and surrounding patients and even affects their life safety. The lesions such as the shoulders and lower back often show varying degrees of softening or induration in the fracture line or osteoporosis will directly produce adverse reactions to joint activities and then cause the development and deterioration of various complications. At present, spiral CT three-dimensional reconstruction technology has been widely used in the field of medical imaging and has played a very important role in the diagnosis and treatment of some diseases. Therefore, combined with three-dimensional reconstruction of spiral CT, this paper discusses its clinical value in the diagnosis of lumbar degenerative osteoporosis. In this experiment, in order to understand the image results after three-dimensional reconstruction, five groups of cases were selected for testing. The test items include the whole lesion site, vertebral imaging, soft tissue lesion site, and lumbar lesion site. In addition, in order to understand the clinical value of spiral CT three-dimensional reconstruction in the diagnosis of lumbar degenerative osteoporosis, this technique was compared and tested with other imaging methods. The selected imaging methods include X-ray, CT, and MRI. The test items include sensitivity, accuracy, positive predictive value, and negative predictive value. To explore the clinical value of spiral CT three-dimensional reconstruction in the diagnosis of lumbar degenerative osteoporosis, from the experimental results, the relevant image clarity and accuracy of the five groups of cases are high, the image quality after three-dimensional reconstruction is good, and the clarity and accuracy are high. In addition, the sensitivity and accuracy of spiral CT three-dimensional reconstruction are higher than those of other imaging methods. It has great clinical value in the diagnosis and treatment of lumbar degenerative osteoporosis.

Initial Results of Phase I/II Study of Azacitidine in Combination with Quizartinib for Patients with Myelodysplastic Syndrome and Myelodysplastic/Myeloproliferative Neoplasm with FLT3 or CBL Mutations

Initial Results of Phase I/II Study of Azacitidine in Combination with Quizartinib for Patients with Myelodysplastic Syndrome and Myelodysplastic/Myeloproliferative Neoplasm with FLT3 or CBL Mutations

Analysis of risk factors and treatment outcome in patients presenting with neglected congenital spinal deformity and neurological deficit.

Congenital spinal deformities (CSD) are uncommon; and usually present during early childhood. Rarely, patients have been reported to present with neglected CSD in association with myelopathy. The current study reports the largest series of patients with neglected CSD and major neuro-deficit; and discusses their long-term outcome. We retrospectively analysed patients with CSD who presented with myelopathy and underwent surgical management between January 2008 and January 2018. Only patients who had complete clinico-radiological records and completed minimum 2-year follow-up were included. Neurology was graded according to American Spinal Injury Association Impairment, Nurick and modified Japanese Orthopaedic Association scores. Radiological details like deformity type, location, magnitude, and underlying anomaly were recorded. A comparative analysis of parameters between pre-operative and final follow-up periods was performed. Thirty three (age = 21.1 ± 11.9years) patients with CSD and myelopathy were included. Mean duration since myelopathy was 5.2 ± 6.2months. Thirty (91%) patients presented with kyphosis or kyphoscoliosis; and 18 had upper thoracic-level lesion (12 and 3 with mid- or low-thoracic and lumbar lesions). 16 (48.5%) and 12 (36.4%) presented with types 1 and 3 anomalies, respectively. Mean pre-operative mJOA and Nurick grades were 8.8 ± 2.4 and 3.4 ± 0.7. Based on ASIA score, 2, 5, 21 and five patients presented with grades A, C, D and E, respectively. All patients underwent surgeries from posterior-only approach. Mean follow-up was 4.7 ± 2.6years. In kyphoscoliosis group, coronal and sagittal Cobb improved by 23.8° and 25.9°, respectively. Mean deformity improved by 19.6° and 15.6° in scoliosis and kyphosis groups, respectively. Neurological status improved in 5, remained stable in 23 and deteriorated in five patients. Mean mJOA and Nurick grades at final follow-up was 8.3 ± 3.1and 3.4 ± 0.9. Major neurological deficit is a rare complication of neglected CSD. In our series, such a presentation was observed in patients with kyphotic or kyphoscoliotic deformities, type 1 or 3 vertebral anomalies and proximal thoracic vertebral lesions. Surgery can be valuable in these patients, as it not only stabilises deformity, but also provides the best chance of preventing neuro-deterioration.

Vertebral metastasis of renal carcinoma at diagnosis. Mechanical and clinical evaluation. Surgical management

Renal cell carcinoma is among the 10 most common cancers. Metastatic disease of the spine is common and 50% of bone metastases are already present at the time of primary diagnosis. Bone metastases from renal cell carcinoma are difficult to manage, especially vertebral localization. A 48-year-old woman was diagnosed with renal cell carcinoma in the context of low back pain. The patient presented two skeleton metastases at diagnosis (T11 and 5th rib). The patient received neoadjuvant treatment with cabozantinib, followed by removal of the renal tumor. Radiotherapy was administered for the lumbar lesion. In spite of the radiotherapy treatment, increased low back pain limiting mobility and ambulation. MRI showed an occupation of the spinal canal, without neurological lesion. The SINS scale revealed a score of 14 (vertebral instability). The patient's prognosis was greater than 12 months according to the Tokuhashi score. Based on clinical and mechanical criteria, surgical treatment of the vertebral lesion was decided. T11 vertebrectomy was performed, the reconstruction was made with an expandable cage, and T8 a L2 posterior spinal arthrodesis. A partial resection of the fifth rib was performed in order to remove the whole macroscopic tumor. After 3 months, she was diagnosed with a local infection, treated by irrigation, debridement and antibiotherapy, with good evolution. At 1-year follow-up, she has no low back pain or functional limitation. Follow-up chest-abdomen-pelvis computed CT scan showed absence of disease progression, furthermore, the vertebral arthrodesis shows fusion signs. At the time of this report, there are no clinical or radiological data of infection.

Incidence of and risk factors for spondylolisthesis, scoliosis, and vertebral fracture in rheumatoid arthritis.

Although lumbar lesions such as spondylolisthesis, scoliosis, and vertebral fracture are not specific to rheumatoid arthritis (RA), the prevalence is high in RA patients. However, no longitudinal study has evaluated lumbar lesions in RA. This study aimed to investigate the incidence of and risk factors for lumbar lesions in RA by a prospective longitudinal cohort study. The study cohort comprised 110 patients with RA from the 'analysis of factors for RA spinal disorders (AFFORD)' study who completed the secondary survey at a single orthopaedic outpatient RA clinic. Radiological examination included standing radiographs and magnetic resonance imaging (MRI) of the lumbar spine. New development of spondylolisthesis, scoliosis, and vertebral fracture were assessed between baseline and secondary survey. The incidences of spondylolisthesis, scoliosis, and vertebral fracture were 42%, 16%, and 12%, respectively, during a mean follow-up of 7years. The independent risk factor for de novo scoliosis was poor control of RA (adjusted odds ratio [aOR] 4.81, p = 0.011), while the independent risk factors for new vertebral fracture was use of glucocorticoid at secondary survey (aOR 14.87, p = 0.012). Patients with de novo scoliosis exhibited more severe low back pain and lower quality of life than those without. The incidence of scoliosis was related in patients with poor control of RA, while new vertebral fracture was more common in patients with use of glucocorticoid. Control of disease activity might be important in preventing radiological lumbar disorders in RA.

Minimally Invasive Contralateral Over-the-Top Approach for Lumbar Calcified Foraminal Lesions: A Technical Note

Various surgical techniques have been described to address intraforaminal/extraforaminal lumbar lesions. They vary from the classic posterior open approaches to minimally invasive techniques with tubular retractors and even endoscopy. These lesions have been approached from either an ipsilateral or a contralateral approach. Only a few reports have described a contralateral minimally invasive tubular approach to address these lesions. However, none of them have been able to address calcified pathologies. We used a contralateral tubular approach to remove the calcified disc herniations in 2 patients presenting with radiculopathy secondary to a calcified intraforaminal L5-S1 disc herniation. Early clinical and radiological outcomes were positive. No perioperative complications occurred. To our knowledge, this is the first report of the expanded use of fixed tubular retractors to address calcified lumbar intraforaminal disc herniations. This approach allows a satisfactory access and view of the contralateral foramen and offending lesion. It permits a wide decompression while preserving the facet joint and thus prevents iatrogenic instability. It can also avoid the iliac crest, which does not allow an ipsilateral extraforaminal approach at the L5-S1 level. This approach is a safe and effective way to treat this specific pathology.