Lumbar-sacral Spine Research Articles

P0194 Osteoporosis and osteopenia as extraintestinal manifestations in ulcerative colitis

Abstract Background Inflammatory bowel diseases (IBD) are often characterized by associated conditions with extraintestinal manifestations that can make diagnosis and treatment difficult. It is known that chronic inflammation, nutritional deficiencies and corticosteroid treatment in IBD are the main risk factors for developing metabolic bone diseases. This study aims to evaluate ulcerative colitis (UC) patients with osteoporosis and osteopenia as extraintestinal manifestation. Methods We analyzed 79 patients (mean age 42 years) with UC and we measured bone mineral density by dual energy X-ray absorptiometry (DXA). Patients who received treatment with corticosteroids were not included in the study. 25(OH)D levels were also measured in all patients enrolled in the study. The patients did not follow vitamin D supplementation treatment. Disease remission was defined with partial Mayo score ≤2. Among the patients included in the study, 52 were under biologic therapy. Results Among the patients included in the study 55 patients (69%) were in remission and 49 patients (62%) with low vitamin D levels <20 ng/ml. Osteoporosis (T score <-2.5) was found in 24% of patients at the lumbar-sacral spine and in 13.9% of patients at the femoral neck; osteopenia (T score between -1.0 and -2.5) was also found in 40.5% of patients at the lumbar-sacral spine and in 35.5% of patients at the femoral neck. All patients with osteoporosis had vitamin D deficiency (p=0.01) and osteopenia was present in 61% of patients with vitamin D deficiency (p=0.05). Regarding disease activity, 23.6% patients in remission and 29.1% patients with active ulcerative colitis were diagnosed with osteoporosis (p=0.69), meanwhile in the osteopenia group, 38.1% patients were in remission and 41.6% patients were with active disease (p=0.84). From the patients included in the study, 65.8% were following biological therapy of which only 3.8% were diagnosed with osteoporosis (p=0.007) and 11.5% were diagnosed with osteopenia (p=0.006). Conclusion Our data confirm that osteoporosis and osteopenia are common extraintestinal manifestations in ulcerative colitis. Patients with vitamin D deficiency were more likely to develop metabolic bone diseases without statistically significant differences between ulcerative colitis patients with active disease or those in remission. Patients who follow biological therapy have a lower risk of developing metabolic bone disease. Screening for osteoporosis and osteopenia is indicated in UC patients and vitamin D supplements are mandatory.

(083) CHRONIC VULVAR PAIN AND URINARY DISTURBANCES REVEALING A LARGE TARLOV CYST IN A 41-YEAR-OLD WOMAN: A CASE REPORT

Abstract Introduction Perineural cysts, also known as Tarlov cysts, are cerebrospinal fluid-filled nerve root cysts predominantly located at the sacral spine. While typically asymptomatic, large Tarlov cysts may elicit discomforting symptoms. Diagnostic challenges stem from limited understanding and symptom overlap with various disorders. Objective This case report explores the presentation of a 41-year-old female patient exhibiting symptoms of vulvar pain and urinary disturbances, which were ultimately attributed to a large Tarlov cyst, highlighting the complexities of diagnosis and management associated with this condition. Methods A 41-year-old female patient with a past medical history of linear scleroderma, chronic left hip pain with leg length discrepancy, and family history of endometriosis presented to her primary care physician with vulvar pain and urinary symptoms. She had burning vulvar pain, predominantly on the left side, radiating from the vulvar vestibule to the perineum, which gradually worsened over 6 months. She also had lower back pain radiating into her legs and calves, along with increased urinary frequency, urgency, retention and burning upon micturition. Patient underwent a 11-month treatment regimen following a referral to pelvic pain specialist, including being initiated on gabapentin and vaginal suppositories, which provided significant pain relief. However, over time, her vulvar pain gradually worsened, and gabapentin was replaced with pregabalin. She underwent six weeks of pelvic floor physical therapy and received a series of peripheral nerve blocks, including multiple pudendal nerve blocks, trigger point injections and hydrodissection of connective tissue around the nerves, yielding little pain relief. Due to persistent vulvar pain, the patient was referred to our clinic. Her examination revealed tenderness upon palpation over the lumbar-sacral spine and sacroiliac joint and para-spinal muscle spasm on the left side. She had provoked vestibulodynia that was predominately on the posterior aspect of the vestibule with a Q-tip test 8/10, and about 4/10 at anterior vestibule. She also continued to have tenderness in her pelvic floor muscles. Given her history and physical exam, a spinal pathology was suspected, and lumbosacral MRI was ordered. Results The lumbosacral MRI revealed a Tarlov cyst measuring 7.7 cm x 3.9 cm x 4.2 cm, extending from the L5-S1 disc level to the S3-S4 vertebral body junction. The patient was subsequently referred to a neurosurgeon who performed a twelve-hour surgery, including a dissection of the intrasacral meningeal cyst that was causing sacral nerve root compression and subsequent wrapping of the weakened right S2-S3 nerve roots. Postoperatively, the pain, although decreased, persisted due to nerve root thinning and long-term compression of the sacral nerve roots. She is currently being managed by our clinic, pain specialists and rehabilitation. A two-year recovery period is anticipated. Conclusions This case underscores the diagnostic challenge of vulvar pain in the context of a Tarlov cyst and emphasizes the necessity for heightened clinical suspicion and comprehensive evaluation. Additionally, the case highlights the importance of considering MRI of the lumbosacral spine as an early investigation in patients presenting with otherwise unexplained chronic vulvar pain, offering a valuable diagnostic tool for identifying conditions like Tarlov cysts that might otherwise remain elusive. Disclosure No.

Clinical Features and Surgical Management of Intramedullary Schwannoma of the Spinal Cord

Background contextIntramedullary schwannoma is a kind of relatively rare tumors with only a few literature reports. This study was aimed to report the clinical characteristics of intramedullary schwannoma and discuss imaging findings and treatment strategies. MethodsThe inclusion criterion was consecutive patients with intramedullary schwannomas who were surgically treated in our institution between 2017 and 2022. Data included clinical characteristics, radiological features, surgical management and prognosis. Clinical and follow-up details of all cases were collected and reviewed. ResultsThere were three males and eight females. The mean age of all patients was 45 years old (Range 26-77 years). Cervical spine (4 cases, 36.4%), thoracic spine (4 cases, 36.4%) and lumbarsacral spine (3 cases, 27.3%) involvement were found respectively. Weakness, numbness and pain of limbs were the main symptoms at administration. Pre-operative MRI all demonstrated lesion with spinal cord medullary invasion and well demarcated margins. The post-operative histological examination all showed benign lesions and confirmed the schwannoma. ConclusionsIntramedullary schwannoma is a very rare tumor. This article presented a series of 11 cases of intramedullary schwannoma with sharp margins and well-enhanced feature. Prognosis and functional recovery were good after gross total resection.

Diagnostic reference levels in spinal CT: Jordanian assessments and global benchmarks.

To reduce radiation dose and subsequent risks, several legislative documents in different countries describe the need for Diagnostic Reference Levels (DRLs). Spinal radiography is a common and high-dose examination. Therefore, the aim of this work was to establish the DRL for Computed Tomography (CT) examinations of the spine in healthcare institutions across Jordan. Data was retrieved from the picture archiving and communications system (PACS), which included the CT Dose Index (CTDI(vol)) and Dose Length Product (DLP). The median radiation dose values of the dosimetric indices were calculated for each site. DRL values were defined as the 75th percentile distribution of the median CTDI(vol) and DLP values. Data was collected from 659 CT examinations (316 cervical spine and 343 lumbar-sacral spine). Of the participants, 68% were males, and the patients' mean weight was 69.7 kg (minimum = 60; maximum = 80, SD = 8.9). The 75th percentile for the DLP of cervical and LS-spine CT scans in Jordan were 565.2 and 967.7 mGy.cm, respectively. This research demonstrates a wide range of variability in CTDI(vol) and DLP values for spinal CT examinations; these variations were associated with the acquisition protocol and highlight the need to optimize radiation dose in spinal CT examinations.

Finite element mechanical analysis of ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery

BackgroundUnilateral bilateral endoscopic spine surgery (UBE) is often performed to treat lumbar spinal stenosis and disc herniation. It has become a prominent method in endoscopic spine surgery because of its very low learning curve and broader operative field of vision. Currently, the ipsilateral approach and contralateral approach have been established for disc herniation in the foraminal area, intervertebral foramen region, or pedicle region. The contralateral method offers many benefits over the ipsilateral approach, including less bone labour during microsurgical decompression and the preservation of facet joints. However, because it uses the interlaminar window approach, it inevitably involves osteotomy of the patient’s superior and inferior articular processes, which may result in corresponding deterioration in the spine’s biomechanical stability and subsequent adjacent facet joint diseases caused by facet joint degeneration postoperatively.ObjectiveAs a result, the purpose of this work is to use a finite element model to evaluate how the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery affect spinal stability while treating identical intervertebral disc herniation.Study designIn this study, a three-dimensional lumbar-sacral spine model was built and verified. Osteotomies were conducted for armpit-type lumbar disc herniation (LDH), periradicular-type LDH, and shoulder-type LDH. Postoperative lumbar spine models of the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery were developed. The von Mises stress on the endplate, shear force on the annulus fibrosus, pressure inside the intervertebral disc, and range of motion (ROM) of the L3 segment were all determined. The results of our well-validated model showed that osteotomy done in the ipsilateral approach deteriorated most biomechanical metrics.ResultsIn the majority of loading conditions, the contralateral approach caused the intervertebral disc’s biomechanical properties to increase, and the ipsilateral approach caused the intervertebral disc’s biomechanical properties to increase sharply more than the contralateral approach.ConclusionThe contralateral approach, which is now extensively employed in unilateral bilateral endoscopic spine surgery, may be regarded as an ideal surgical alternative for treating lumbar disc herniation without producing iatrogenic instability. This approach has a low facet joint reduction rate, minimum soft tissue injury, and precisely identifies the midline of the central spinal canal during the retraction of the thecal sac and nerve roots.

A Rare Case Report of Sirenomelia

Sirenomelia, which is also known as mermaid syndrome, is an extremely rare congenital developmental disorder characterized by anomalies of the lower spine and the lower limbs. Affected infants are born with partial or complete fusion of the legs. Additional malformations may also occur including genitourinary abnormalities, gastrointestinal abnormalities, anomalies of the lumbar-sacral spine and pelvis and absence or underdevelopment (agenesis) of one or both kidneys. Affected infants may have one foot, no feet or both feet, which may be rotated externally. The tailbone is usually absent, and the sacrum is partially or completely absent as well. Additional conditions may occur with sirenomelia including imperforate anus, spina bifida, and heart (cardiac) malformations. The incidence of sirenomelia is 8-1 case/100000[1] births with male to female ratio being 3:1.[2] Sirenomelia has no definite cause, almost all cases occur without any reason.
 Previously, some literatures mentioned that sirenomelia is the severe form of caudal regression syndrome and has many developmental disorders. Recently much literature mentioned sirenomelia is similar but a different disorder. NORD has a different report on caudal regression syndrome.

Multifocal Tuberculosis with Bilateral Adrenal Involvement: A Case Report

Tuberculosis can affect all endocrine glands including the hypothalamus, pituitary gland, thyroid and adrenal glands. The endocrine gland most affected by tuberculosis is the adrenal gland. The adrenal location of tuberculosis accounts for less than 2% of adrenal incidentalomas. It is the most common infectious cause of adrenal insufficiency. We report the case of a 31-year-old patient hospitalized for confirmed tuberculous spondylodiscitis. The CT scan showed a discal-vertebral damage of the dorsal- lumbar-sacral spine with epiduritis and multiple abscessed prevertebral collections and of the iliac psoas muscle, complicated by a posterior wall recession considered as a dorsolumbar and sacral pott’s disease, considering the context, associated with the discovery of deep necrotic abdominal adenopathies with bilateral involvement of the adrenals involving the body and the internal arm of the left adrenal gland and the two arms of the right adrenal gland, which are the site of hypodense collections.

Multifocal Tuberculosis with Bilateral Adrenal Involvement: A Case Report

Tuberculosis can affect all endocrine glands including the hypothalamus, pituitary gland, thyroid and adrenal glands. The endocrine gland most affected by tuberculosis is the adrenal gland. The adrenal location of tuberculosis accounts for less than 2% of adrenal incidentalomas. It is the most common infectious cause of adrenal insufficiency. We report the case of a 31-year-old patient hospitalized for confirmed tuberculous spondylodiscitis. The CT scan showed a discal-vertebral damage of the dorsal- lumbar-sacral spine with epiduritis and multiple abscessed prevertebral collections and of the iliac psoas muscle, complicated by a posterior wall recession considered as a dorsolumbar and sacral pott’s disease, considering the context, associated with the discovery of deep necrotic abdominal adenopathies with bilateral involvement of the adrenals involving the body and the internal arm of the left adrenal gland and the two arms of the right adrenal gland, which are the site of hypodense collections.

The use of computer thermography in the diagnosis of diseases of the lumbosacral spine in athletes and ballet dancers

The experience in thermographic examination of 108 patients (athlets and ballet dancers) with lumbar-sacral spine diseases is presented. All patients have been treated at the CITO Department of Sports and Ballet Injury during the period from 1987 to 2002. Various thermograms typical of osteochondrosis, spondyloarthrosis, spondylolysis and ligamentous pathology of lumbar-sacral spine are given and described. Thermography is shown to be a nonspecific examination method which only defines more precisely the clinical and radiologic data. The main value of thermography is the possibility to detect the activity of the pathologic process and to retrace the dynamics of the disease development during follow up and treatment.

Роль нестероїдних протизапальних препаратів у лікуванні больового синдрому при дегенеративно-дистрофічних захворюваннях попереково-крижового відділу хребта

Актуальність. Дегенеративні ураження поперекового відділу хребта і пов’язані з ними клініко­неврологічні прояви є однією з найбільш важливих проблем сучасної ортопедії. Золотим стандартом лікування больових синдромів у ділянці хребта є нестероїдні протизапальні препарати (НПЗП). Мета: оцінити ефективність застосування НПЗП у лікуванні больового синдрому в пацієнтів із дегенеративно­дистрофічними ураженнями хребта. Матеріали та методи. Обстежено 120 пацієнтів (78 жінок і 42 чоловіки) віком 39,77 ± 5,20 (від 32 до 78) року з діагнозом остеохондрозу, протрузії або грижи міжхребцевого диска, поперекового спинального стенозу, які проходили курс консервативного лікування в стаціонарі відділення реабілітації ДУ «Інститут травматології та ортопедії НАМНУ». Оцінка ефективності лікування проводилася за опитувальником Роланда — Морріса, ВАШ, Оswestry Disability Index і індексом одужання, даними рентгенографії і неврологічного огляду. Результати. Відзначено високу ефективність НПЗП та міорелаксантів у лікуванні нейрокомпресійного больового синдрому в пацієнтів за даними ВАШ відразу після лікування (покращення спостерігали у 88 (73,4 %) пацієнтів, незадовільний результат — у 12 (9,8 %)) і через 6 місяців (у 65 (54,1 %) пацієнтів — відмінний результат і без змін — у 18 (15,1 %)). Аналогічна тенденція спостерігалася за результатами анкетування Роланда — Морріса і Оswestry Disability Index. Однофакторний дисперсійний аналіз показав, що наявність сколіозу, спондилолістезу, нестабільності L4­L5 і деформуючого артрозу кульшових суглобів у пацієнтів є негативною прогностичною ознакою ефективності лікування. Висновки. Застосування НПЗП у комбінації з міорелаксантами дає позитивний ефект: знижує больовий синдром, покращує показники порушення життєдіяльності як у найближчому, так і у віддаленому періоді лікування.

Новые подходы в лечении болевого синдрома в пояснично-крестцовом отделе позвоночника

Актуальность. Боль в поперечно-крестцовом отделе позвоночника остается одной из наиболее актуальных медицинских и социальных проблем. Задачей исследования было оценить эффективность комбинированного использования трансфораминальной и каудальной эпидуральных блокад для лечения болевого синдрома пояснично-крестцового отдела позвоночника на фоне дегенеративно-дистрофических заболеваний. Материалы и методы. В исследование были включены 228 (85 мужчин, 143 женщины) больных с болью в пояснично-крестцовом отделе позвоночника в возрасте 52,07 ± 13,95 года, которым были проведены трансфораминальные эпидуральные блокады (n = 114) или каудальные эпидуральные блокады (n = 114). Результаты. Положительный эффект был зарегистрирован в 150 (65,8 %) случаях. У остальных 78 пациентов при восстановлении болевого синдрома до 5 и более баллов по визуальной аналоговой шкале были выполнены повторные процедуры общим количеством до четырех в течение 4–14 дней после первой блокады. Их разделили на три группы: в группе 1 пациентам повторно провели трансфораминальные эпидуральные блокады (n = 26), в группе 2 — каудальные эпидуральные блокады (n = 26), в группе 3 — комбинированное применение трансфораминальной и каудальной эпидуральных блокад (n = 26). В начале интервенции, через 1 час, 3 недели и 3 месяца во всех группах определяли интенсивность болевого синдрома, симптомы натяжения (проба Ласега), объем активных движений в поясничном отделе позвоночника и качество жизни (индекс инвалидности Освестри). Выводы. Установлено, что комбинированное использование трансфораминальной и каудальной эпидуральных блокад является наиболее эффективным методом лечения болевого синдрома в пояснично-крестцовом отделе позвоночника и связано с положительной динамикой качества жизни пациентов. Трансфораминальные или каудальные эпидуральные блокады были также эффективны, но только в краткосрочной перспективе.

Biomechanics of adjacent segment after three-level lumbar fusion, hybrid single-level semi-rigid fixation with two-level lumbar fusion

Multi-level spinal fusion has been reported in some cases to lead to adjacent segment disease (ASD) and proximal junctional kyphosis (PJK). The purpose of this study was to demonstrate a polyether-ether-ketone (PEEK) rod fixation system implanted adjacent to a two-level lumbar fusion would have a lower risk of PJK than three-level lumbar fusion, which was investigated by comparing the biomechanical effects on the adjacent level after surgical procedures. Four finite element (FE) models of the lumbar-sacral spine (intact model (INT), L4-S1 fusion model (L4-S1 FUS), L3-S1 fusion model (L3-S1 FUS), and single-level PEEK rod semi-rigid fixation adjacent to L4-S1 fusion model (FUSPRF)) were established. Displacement-controlled finite element (FE) analysis was used during the simulation. Compared with the two-level fusion model (L4-S1 FUS), both three-level implanted models (L3-S1 FUS and FUSPRF) showed an increase intersegmental rotation angle, and maximum von-Mises stress on the disc annulus. The results also showed that the intersegmental rotation, stress on the disc annulus and maximum stress on the rod were lower in the FUSPRF model than the L3-S1 FUS model. Though the maximum screw stress was higher in the FUSPRF model than the L3-S1 FUS model under all moments except for torsion, the maximum screw stress in the two models were far below the yield strength of titanium alloy. As the parameters above have been indicated as risk factors for PJK, it can be concluded that hybrid single-level PEEK rod semi-rigid fixation and two-level lumbar fusion have a lower risk of PJK than three-level lumbar fusion.

Biomechanical comparison of 3 types of transdiscal fixation implants for fixing high-grade L5/S1 spine spondylolisthesis

BACKGROUND CONTEXTThere are several options for the stabilization of high-grade lumbosacral spondylolisthesis including transdiscal screws, the Bohlman technique (transdiscal fibular strut) and the modified Bohlman technique (transdiscal titanium mesh cage). The choice of an optimum construct remains controversial; therefore, we endeavoured to study and compare the biomechanical performance of these 3 techniques. PURPOSEThe aim of this study was to compare 3 types of transdiscal fixation biomechanically in an in vitro porcine lumbar-sacral spine model. STUDY DESIGN/SETTINGPorcine cadaveric biomechanical study. METHODS18 complete lumbar-sacral porcine spines were split into 3 repair groups, transdiscal screws (TS), Bohlman technique, and a modified Bohlman technique (MBT). Range of motion (L3 – S1) was measured in an intact and repaired state for flexion, extension, left/right lateral bending, and left/right torsion. To recreate a high-grade lumbosacral spondylolisthesis a bilateral L5/S1 facetectomy, removing the intervertebral disc completely, and the L5 body was displaced 50%–60% over the sacral promontory. Results were analyzed and compared to intact baseline measurements. Standard quasi-static moments (5 Nm) were applied in all modes. RESULTSAll range of motion (ROM) were in reference to intact baseline values. TS had the lowest ROM in all modes (p=.006–.495). Statistical difference was found only in extension for TS vs. BT (p=.011) and TS vs. MBT (p=.014). No bone or implant failures occurred. CONCLUSIONTS provided the lowest ROM in all modes of loading compared to Bohlman technique and MBT. Our study indicates that TS results in the most biomechanically stable construct. CLINICAL SIGNIFICANCEKnowledge of the biomechanical attributes of various constructs could aid physicians in choosing a surgical construct for their patients.

Evaluation of the Frequency of Pain Occurrence of the Lumbar Spine Measured in the Employees of Szczecin’s Universities Depending on Age and Pathomechanisms

Introduction: With age, there are many pathologies in the organs of our body. The sedentary lifestyle in specific professional groups cause the emergence and intensification of functional and structural defects of the spine. Aim: The aim of the study was to examine the frequency of pelvic and lumbar spine disorders (measured using functional tests and imaging tests) affecting the frequency of pain. Material and Methods: The study involved 114 patients with lumbosacral pain (75 women, 39 men, 24-85 years of age, average age of the respondent 53 years). It was carried out between July 2017 and September 2019 at SP ZOZ SW in Szczecin. In the study group, the author’s questionnaire was used, functional tests were carried out and imaging analysis was performed. Results: The frequency of occurrence of pain episodes depends statistically significantly on the age (p <0.05). The highest percentage of frequent pain occurs in people over 65 years of age (70.83%). Over half (57.02%, n = 65) of respondents struggle with pain in the ilio-lumbar and / or sacro-tumor ligaments. Strong pain in the ilium-lumbar ligament is statistically significant in people with lumbar hyperlordosis (84.62%, n = 22). This relationship was also observed during the lifting of hands. For 6 people declaring the pain while doing this - 4 of them also show severe pain in the ilio-lumbar ligaments. The pain of the cruciate ligament alleviates the standing position, which is also statistically significant. In the employees of the Szczecin universities, the disc herniation of the intervertebral disc was most often found in people between the 4th and 6th decade of life. Pain discomfort associated with discopathy accompany patients throughout all day (p <0.05). Conclusions: The degree of advancement of changes in the lumbar-sacral spine increases with age. The type of lumbar lordosis affects pain in the ilium-lumbar ligament.

Buried island transposition flap for joint Plastic-Neurosurgical management of spinal wound dehiscence – a technical note and single Centre experience

Introduction Spinal surgical wound infection can lead to tissue voids between the spine and skin that can be difficult to reconstruct. Previously described techniques include myocutaneous flaps or perforator based fasciocutaneous flaps. However, these procedures can be time-consuming and surgically challenging. Aims This study aimed to assess the effectiveness of a novel technique employing a buried island transposition (BIT) flap, for the repair of non-irradiated dehisced spinal wounds. Methods Fifteen patients with failed conservative management of infected midline posterior spinal wounds, underwent wound repair using a local buried islanded de-epithelialized double-breasted fasciocutaneous transposition flap, performed by joint input from the neurosurgical and plastic surgical teams. Results Mean age was 58 years (range, 31–76 years) with male-to-female ratio of 8:7. The BIT flap was used to repair four wounds in the cervical spine with underlying fixation; four wounds in the thoracic spine with underlying fixation; and seven wounds in the lumbar-sacral spine, of which three had underlying fixation. Pre-operatively, each of the wounds were either dehiscent with exposed hardware, or had large defects unsuitable for primary closure following debridement. There was no procedure-related mortality. All patients demonstrated good wound healing with no subsequent repeat surgery or removal of spinal fixation at mean 24-month follow-up. Conclusion We successfully used a novel buried island transposition flap that has not previously been described in repair of spinal wounds. This technique, which led in all cases to good wound healing and prevented removal of metalwork, has comparable efficacy but increased ease of use compared to traditional techniques. It requires redundant skin at the wound site.

Navigated percutaneous versus open pedicle screw implantation using intraoperative CT and robotic cone-beam CT imaging.

Percutaneous paraspinal pedicle screw implantation (PPSI) reduces soft tissue trauma, blood loss, and postoperative pain but remains technically challenging and associated with radiation exposure and implant-related artefacts. Here, we determined the feasibility, screw accessibility, and the accuracy of navigated PPSI in the thoraco-lumbar sacral spine using intraoperative computed tomography (iCT) and robotic cone-beam CT (CBCT) imaging. Between 2015 and 2018, 465 percutaneous paraspinal pedicle screws were implanted in 75 patients using iCT- or CBCT-based spinal navigation with 230 screws connected to rod reducers during screw assessment imaging (iCT 198; CBCT 32). Clinical and demographic data, intraoperative screw accessibility, and screw accuracy were analyzed and compared to a case-matched cohort of 75 patients undergoing navigated implantation of 481 pedicle screws through an open midline approach. Both iCT and CBCT permitted reliable assessment of each implanted screw, regardless of artifacts caused by rod reducers. Although overall accuracy for correct placement was comparable between PPSI and open surgery (PPSI 96.6%; Open 94.2%), PPSI compared favorably to open surgery regarding complete placement within the pedicle (PPSI 90.1%; Open 75.1%; p < 0.0001), regional placement accuracy in the lumbar (PPSI 97.8%; Open 91.5%; p < 0.001), and lumbar-sacral spine (PPSI 100%; Open 81.2%; p < 0.05), next to the duration of surgery and length of hospitalization. PPSI with iCT- and CBCT-based spinal navigation improves the accuracy, safety, and workflow of navigated spinal instrumentation. Next, a cost-effectiveness and outcome analysis should determine whether iCT and CBCT imaging are truly economically justified. These slides can be retrieved under Electronic Supplementary Material.

Evaluation of spine structure stability at different locations during SBRT.

Modern stereotactic body radiotherapy (SBRT) techniques and systems that use online image guidance offer frameless radiotherapy of spinal tumors and the ability to control intrafraction motion during treatment. These systems allow precise alignment of the patient during the entire treatment session and react immediately to random changes in this alignment. Online tracking data provide information about intrafractional changes, and this information can be useful for designing treatment strategies even if online tracking is not being used. The present study evaluated spine motion during SBRT treatment to assess the risk of verifying patient alignment only prior to starting treatment. This study included 123 patients treated with spine SBRT. We analyzed different locations within the spine using system log files generated during treatment, which contain information about differences in the pretreatment reference spine positions by CT versus positions during SBRT treatment. The mean spine motion and intra/interfraction motion was evaluated. We defined and assessed the spine stability and spine significant shifts (SSHs) during treatment. We analyzed 462 fractions. For the cervical (C) spine, the greatest shifts were in the anterior-posterior (AP) direction (2.48 mm) and in pitch rotation (1.75 deg). The thoracic (Th) spine showed the biggest shift in the AP direction (3.68 mm) and in roll rotation (1.66 deg). For the lumbar-sacral (LS) spine, the biggest shift was found for left-right (LR) translation (3.81 mm) and roll rotation (3.67 deg). No C spine case exceeded 1 mm/1 deg for interfraction variability, but 7 of 54 Th spine cases exceeded 1 mm interfraction variability for translations (maximum value, 2.5 mm in the AP direction). The interfraction variability for translations exceeded 1 mm in 2 of 24 LS spine cases (maximum value, 1.7 mm in the LR direction). Only 13% of cases had no SSHs. The mean times to SSH were 6.5±3.9 min, 8.1±5.9 min, and 8.8±7.1 min for the C, Th, and LS spine, respectively, and the mean recorded SSH values were 1.6±0.66, 1.43±0.33, and 1.46±0.47 mm/deg, respectively. Positional tracking during spine SBRT treatments revealed low mean translational and rotational shifts. Patient immobilization did not improve spine shifts compared with our results for the Th and LS spine without immobilization. For the most precise spine SBRT, we recommend checking the patient's position during treatment.

SACROILIAC JOINT PATHOLOGY IN ELDERLY PATIENTS WITH LOW BACK PAIN (OBSERVATION PROGRAM “IOLANTA”)

Pain in the lower back is one of the frequent reasons for seeking medical help among people over 60 years of age. The study of this problem is of interest to specialists of various profiles, including neurologists, rheumatologists, orthopedic surgeons and therapists. Purpose — to determine prevalence rate of sacroiliac joint pathology in elderly patients with low back pain (LBP) in conjunction with evaluation of clinical significance of bone resorption and cytokines markers. Materials and Methods.The study was conducted with consecutive inclusion of patients (n = 259) with mean age of 65.5 year old [62.5; 69.5] who addressed the hospital for the first time in calendar year with complaints for low back pain. The authors performed MRI examination of lumbar-sacral spine and sacroiliac joint, assessed transforming growth factor β1 (TGF β1), interleukin (IL) 1β and IL-6, Beta-Crosslaps (β-CrossLaps) criteria, P1NP (N-terminal propeptide of procollagen type I) concentration and deoxypyridinoline (DPD) level. Results. 39.4% of patients older 60 years with low back pain on MRI demonstrated changes in sacroiliac joints with statistically significant higher (p = 0.037) pain level as compared to patients without pathology of sacroiliac joint, as well as higher values of TGF-β1 (p = 0.033), IL-1β (p = 0.028), IL-6 (p = 0.041), β-CrossLaps (p = 0.028), P1NP (p = 0.037) and DPD (p = 0.002). Conclusion. Reported alterations in sacroiliac joint conditioned by degenerative and dystrophic processes are associated with distinctive signs of osteoarthrosis and confirm non-specific inflammation active with bone resorption in patients with low back pain.

A phantom study for the optimization of image quality and radiation dose for common radiographic examinations in digital radiography

Introduction: Phantom studies facilitate the implementation of radiation dose surveillance as a function of radiographic technical parameters for minimizing patient radiation dose. The evidence of such investigations can then be used to evaluate technical parameters used in the radiographic procedures to reduce radiation dose without compromising the image quality. Material and Methods: This experimental study was carried out using an anthropomorphic phantom and the Leeds test object. Computed radiographic system was utilized and the images were printed for objective evaluation. Dose-area-product (DAP) readings were obtained using a DAP meter for the technical parameters employed for the radiographic procedures. Results: The use of 0.2 mm additional copper filtration resulted in the lowest radiation doses for all four radiographic procedures (i.e. posteroanterior chest, anteroposterior abdomen and lumbar sacral spine projections). The highest tube potential appropriate to the body part being imaged, patient size, image receptor response and required information resulted in the minimum radiation dose to the patient without compromising the image quality. The focus to film distance utilized for the radiographic procedure must be in accordance with the focus to grid distance specified by the manufacturer when using the bucky to eliminate grid “cut-off.” Conclusion: The optimization of image quality and radiation dose can be accomplished by using a phantom and selecting the imaging parameters that yield an acceptable image quality with the lowest entrance surface dose while considering the adjustment for patient size.

БОЛЬОВІ ТА ВЕРТЕБРОГЕННІ СИНДРОМИ У ХВОРИХ НА РОЗСІЯНИЙ СКЛЕРОЗ (ОГЛЯД ЛІТЕРАТУРИ)

Multiple sclerosis (MS) is the most prevalent disease of the central nervous system (CNS), that causes persistent disability of young people at the working age. Among the most frequent MS syndromes are coordinative disorders, visual disturbances, central pareses, pelvic disorders, sense of discomfort, but not pain. It has been established that half of these patients suffer from chronic pain. Very often the pain is the first manifestation of MS (in up to 11% cases). The article presents the features of pain syndromes, as well as spinal diseases as manifestations of comorbid states in MS. We have also analyzed their connection with clinical features of the MS course. The problem of pain syndrome in MS patients becomes more and more important nowadays. Recent studies suggest that at least 2/3 of patients with this ailment have pain to varying degrees and at least 40% of them characterized their pain as persistent one. MS patients in the presence of pain syndrome are more disabled and socially disadapted than those with a similar neurological defect without pain syndrome. Patients with MS presenting with pain syndrome predominantly have headache, pain in the cervical-thoracic and lumbar-sacral spine, and neuropathic pain in the lower limbs. Taking into account the urgency of the problem of pain and vertebrogenic syndromes in demyelinating diseases, it requires close attention and further study. Vertebrogenic syndromes in MS develop due to the influence of several factors, mostly, centers of demyelination, dystrophic changes in the spine and osteoporosis. In MS, vertebrogenic syndromes have their own hallmarks. It is an early onset, a long-term pain without clear periods of deterioration and improvement, moderately evident muscular-tonic disorders that are observed in all parts of the spine. Neurological disorders in MS accelerate development of diverse functional and organic (dystrophic) processes in the spine. Often, vertebrogenic and pain syndromes precede the widespread clinical picture of the disease, when patients for months and years are treated by manual therapists, and sometimes by neurosurgeons. Only a timely observation by neurologist and MRI of the brain and spinal cord can establish the correct diagnosis.