Lumbosacral Region Research Articles

Effect of cervical and lumbosacral spina bifida cystica on volumes of intracranial structures in children.

Spina bifida is a major disorder that occurs when the membranes of the spinal cord and medulla fail to close during the embryonic period and affects the individual for the rest of life. Some physical, mental, and social difficulties can be observed in the lives of children with spina bifida after surgery. The aim of this study is to determine what kind of volumetric changes occur in the brain when spina bifida occurs in different regions of the cord. The volume of intracranial structures of 14 children aged 1 to 9years (7 cervical, 7 lumbosacral) with different levels of spina bifida compared with vol2Brain. Spina bifida occurring in the cervical region was found to cause a greater volumetric reduction in subcortical structures, cortex and gyrus than spina bifida occurring in the lumbosacral region. We believe that our study will help clinicians involved in the management of this disorder.

The Use of Stromal Vascular Fraction in Long Bone Defect Healing in Sheep.

The objectives of the present study were to evaluate (a) the feasibility of using stromal vascular fraction (SVF) and nanocrystalline hydroxyapatite (nHA) paste in combination for the treatment of segmental bone defect, (b) the quality of the callus produced, (c) the potential improvement of the autograft technique, and (d) the direct comparison of the biomaterial to the use of autogenous cancellous bone. Unilateral, segmental mid-diaphyseal bone defect was created on the right metatarsus of skeletally mature sheep animals (n = 24) under anesthesia (D0). Residual segments were stabilized by stainless-steel plates and appropriate screws. Defects were managed as follows: group A: use of nHA paste to filling, group B: use of autogenous bone graft mixed with nHA bone paste, placed in defect, group C: use of SVF mixed with nHA bone paste injected into defect, group D: use of bone graft and SVF with nHA paste before apposition in bone defect. SVF had been previously isolated from adipose tissue of the animals intra-operatively after digestion with collagenase solution and neutralization. Animals were evaluated clinically and by X-raying and ultrasonographic examination of the defect, at regular intervals, until D90. Ultrasonographic assessment performed along the length of the defect included calculation of the length of the bone defect and assessment of vascularization. SVF was successfully isolated from group C and D animals, with the average yield being 1.77 × 106 cells. The comparison of clinical scores (based on the 'Kaler scale') on each post-operative day indicated significant differences between the four groups on D1 to D30 (p < 0.01); the median clinical score within group A was 2.5 for D1-D30 and 1 for the entire period; respective scores for other groups were 1.5 (p = 0.07) and 0 (p = 0.033). Differences in radiographic assessment scores were significant for scores obtained on D60 (p = 0.049) and D90 (p = 0.006). There was a significant difference between the four groups in the length of the bone defect, as assessed ultrasonographically, for the entire length of the study; median values were 8, 8.5, 6, and 8 mm for groups A, B, C, and D, respectively (p = 0.008). There was a significance in the differences between median scores obtained during the histopathological examination: 2, 11, 13.5, and 12 for group A, B, C, and D (p = 0.022). There was an inverse correlation between the overall scores of histopathological evaluations and the length of the bone defect (observed on D90) (p < 0.0001) and a correlation between the overall scores and the radiographic assessment scores (obtained on D90) (p < 0.0001). This is the first study in which the efficacy of fresh autologous Stromal Vascular Fraction (SVF) from adipose tissue in enhancing bone healing in a long, weight-bearing, diaphyseal bone was evaluated. It is concluded that the lumbosacral region was an attractive site for harvesting adipose tissue, the use of SVF contributed to faster rehabilitation post-operatively, and SVF significantly enhanced bone formation; in general, the results indicated an osteogenic potential of SVF comparable to the gold standard autologous bone graft.

Surgical intervention for the correction of fecal impaction in an obstipated cat with an old compression injury in the lumbosacral region of the spine

BackgroundFeline obstipation is a clinical condition often manifested by defecation inability that results in fecal impaction. This is frequently associated with a blunt traumatic injury that affects mostly the spine and surrounding structures in the caudal part of the back leading to vertebral compression.Case presentationA 6-month-old, female, mixed-breed cat of 1.49-kg BW was presented with a history of prolonged constipation (i.e., obstipation) along with discomfort and weakness. Prior to the presentation, the cat was medically treated with dietary fibers, fecal softeners, and enemas, but obstipation persisted. Clinical examinations revealed that there was straining but not effective for defecation. In addition, the cat had poor appetite and dehydration, electrolyte abnormalities, and defects in posture and gait. The lumbosacral region showed a depression that was supposed to be the consequence of an old, untreated regional injury. Radiographic imaging indicated a marked ventral curvature in the lumbosacral spine including major deviations in the positions of the L6 and L7 vertebrae and the sacrum as well. A firm tubular structure was felt on ventral abdominal palpation, and further ultrasonography revealed the tubular impaction. Laparotomy exposed a definite large bowel impaction, and enterotomy was performed to evacuate the firm feces. Postoperatively, supportive medications and care were provided for better recovery. However, the impaction recurred within 3 months after surgery, and euthanasia was a further choice.ConclusionsTraumatic injuries involving the lumbosacral spine in cats might be serious enough to lead to severe constipation and thereby bowel impaction. Therefore, treatment should be prompt and accurate in any case of spinal injury to avoid further complications.

Anterior versus Posterior Approach in Surgical Treatment of Tuberculous Spondylodiscitis of Thoracic and Lumbar Spine

Background Spinal tuberculosis is the most common encountered extra-pulmonary form of the disease and accounts for around 50% of musculoskeletal tuberculosis cases, thoracic spine is the most commonly affected, and involvement of lumbar and lumbosacral region is less common, spinal tuberculosis can cause severe neurological deficits, kyphotic deformities, and paraplegia. Aim of the Work The aim of this study is review the literature comparing the clinical, radiological and functional outcome of anterior versus posterior surgical debridement and fixation in patients with thoracic and lumbar tuberculous spondylodiscitis. Patients and Methods In this meta-analysis, we combined 25 studies that compared the clinical outcomes of the anterior and posterior approaches in treating 1797 patients with thoracic and lumber spinal TB. This study was approved by the Ethics Committee of Ain Shams University Faculty of Medicine. Written informed consent was not needed because of the study design (systematic review). Based on patient safety and the efficacy of the procedures, we raised three clinically crucial questions to determine the optimal surgical procedure in treating thoracic and lumbar tuberculosis. The primary data used as evidence to answer these questions were obtained from the treatment results, such as the radiologic data and patient-related outcomes. Results The results showed that there is no statically significant different in the operative time for the anterior approach (220.8-51.5 minutes) versus posterior approach (213.9-69.3 minutes), and no statistically significant difference was detected. Blood loss was significantly greater in the anterior approach (1125.0-275.5 mL) than in the posterior approach (710.4-192.4 mL). Conclusion The posterior approach showed a higher potential for maintaining the correction of deformity and a lower overall surgical complication rate; however, both groups showed no statistically significant differences in operative time, blood loss, radiological and clinical outcome; therefore posterior approach could be used as an alternative procedure to treat thoracic and lumbar tuberculosis patients in terms of pain control, Cobb’s angle, and reduction of complications, however; posterior-only approach alone cannot be used in cases of anterior abscess formation or multilevel involvement where an anterior debridement is mandatory, so; when deciding among the two procedures for treatment of thoracic and lumbar spinal tuberculosis, surgeons must thoroughly consider the patient’s specific features of spinal tuberculosis, the surgeon’s own surgical experience, the risks of surgical complications ranging from neurological to structural, and the different possible outcomes.

A RARE CAUSE OF RADICULOPATHY: FEMORAL HEAD AVASCULAR NECROSIS

Insufficient blood flow to the proximal femur causes osteonecrosis of the femoral head, which is known as femoral head avascular necrosis (AVN). The underlying pathogenesis is unclear, risk factors are likely to influence microcirculation somewhat, but this has not been confirmed by research. In more than 75% of cases, avascular necrosis affects the femoral head. Methods: From August 2019 to March 2022, 4 patients with FBAN were analyzed retrospectively. The findings seen in the hip MRI radiographs of the patients were reported radiologically as FBAN. It was staged with the Ficat and Arlet classifications. Visual analog scale (VAS) was used in the current clinics of the patients. Results: Patients with severe back, hip, and leg pain whose clinic and radiology do not match with lumbar pathology should plan a hip MRI. Because of this, it may be misleading for people with severe radiculopathy, and this radiculopathy may not even be real. The pain is really coming from the hip, but it is often felt in the lumbosacral region and the buttocks. This makes it easy to make the wrong diagnosis.

Case Report on Myleomeningiocele with Cerebellar Tonsillar

Myelomeningocele is a form of neural tube abnormality that causes the spinal cord and meninges to protrude through a hole in the spinal column. It is uncommon for myelomeningocele to be associated with cerebellar tonsillar herniation. This instance demonstrates the difficulties in detecting and controlling this comorbid illness. Myelomeningocele with cerebellar tonsillar herniation is a severe congenital disorder involving the protrusion of the spinal cord and meninges through a defect in the vertebral column, accompanied by downward displacement of the cerebellar tonsils. It is associated with significant neurological and physical impairments, requiring comprehensive medical management and rehabilitation. Early diagnosis, intervention, and on-going multidisciplinary care are crucial for individuals affected by this condition to maximize their potential and improve their overall well-being. We present a case of a female child who was admitted to the NICU for further evaluation and management of myelomeningocele. On examination, the child was active with vitals stable. On local examination, swelling is present at the Lumbosacral region of size 5*4 cm. All investigations and septic screens sent reports within normal limits. MRI was done s/o Spina bifid occulta with LS myelomeningocele with cerebellar tonsillar descent (likely Arnold Chiari Malformation type.

Use of ultrasound to estimate the prevalence of occult spinal dysraphism in children undergoing urogenital and anorectal surgeries: A cross-sectional study.

The use of ultrasound has immensely increased the safety toward regional blocks and central venous access and has been considered as the standard of care for securing central access. The aim of this study is to estimate the prevalence of occult spinal dysraphism using ultrasound in children less than 2 years of age undergoing elective urogenital or anorectal surgery. The lumbosacral region of 159 American Society of Anesthesiologists (ASA) category I/II patients, posted for elective urogenital and anorectal surgery was scanned with ultrasound, prior to giving caudal block. The prevalence of occult spina bifida was 3% in our study. There was no statistically significant association of cutaneous marker with abnormal scan. Prevalence of occult spina bifida was ten-times higher in our study than in the general population. Perioperative ultrasound screening of the lower spinal anatomy by anesthesiologist done prior to performing neuraxial block is worthwhile in ruling out occult spinal anomalies in high-risk children of occult spinal dysraphism.

The Cross-Sectional Area Assessment of Pelvic Muscles Using the MRI Manual Segmentation among Patients with Low Back Pain and Healthy Subjects.

The pain pathomechanism of chronic low back pain (LBP) is complex and the available diagnostic methods are insufficient. Patients present morphological changes in volume and cross-sectional area (CSA) of lumbosacral region. The main objective of this study was to assess if CSA measurements of pelvic muscle will indicate muscle atrophy between asymptomatic and symptomatic sides in chronic LBP patients, as well as between right and left sides in healthy volunteers. In addition, inter-rater reliability for CSA measurements was examined. The study involved 71 chronic LBP patients and 29 healthy volunteers. The CSA of gluteus maximus, medius, minimus and piriformis were measured using the MRI manual segmentation method. Muscle atrophy was confirmed in gluteus maximus, gluteus minimus and piriformis muscle for over 50% of chronic LBP patients (p < 0.05). Gluteus medius showed atrophy in patients with left side pain occurrence (p < 0.001). Muscle atrophy occurred on the symptomatic side for all inspected muscles, except gluteus maximus in rater one assessment. The reliability of CSA measurements between raters calculated using CCC and ICC presented great inter-rater reproducibility for each muscle both in patients and healthy volunteers (p < 0.95). Therefore, there is the possibility of using CSA assessment in the diagnosis of patients with symptoms of chronic LBP.

Extensive mongoloid spots in mucopolysaccharidosis Type I Hurler syndrome

Lysosomal storage diseases are inherited metabolic disorders that are caused by enzyme deficiencies within the lysosomes. The most common lysosomal storage disorder associated with Mongolian spots (MSs) is GM1 gangliosidosis Type-1. We are reporting a case of Hurler disease with extensive MS. A 9-month-old girl, born to a consanguineously married couple, presented with a developmental delay with uneventful birth history. The presence of multiple mongoloid spots over the lumbosacral region and lateral abdominal wall was noticed since birth. Examination showed coarse facies with a depressed nasal bridge and a low-set ear. Multiple mongoloid macules were noted in the lumbosacral region. Serum enzyme assay level had decreased activity of alpha-L-iduronidase (IDUA). Exome sequencing revealed a homozygous mutation in exon 8 of the IDUA gene. Extensive MS can be seen in mucopolysaccharidosis (MPS) Type 1 in addition to commonly described GM1 gangliosidosis. The early diagnosis helps to start enzyme replacement therapy in MPS Type I, compared to currently no specific treatment available for GM1 gangliosidosis.

The study on the prevalence of Mongolian spots in the neonates.

Mongolian Spots (MS) generally exist at the time or under the first few weeks of the neonate life-cycle, often considered a birthmark, characterized by hyper-pigmented marks especially bluish-black hue that cannot vanish easily and are generally found on the lumbosacral region. As this MS is reminiscent of bruises and appears to be caused by abuse, this may raise questions about the possibility of abuse. Hence, it is significant to identify MS bruises. The objective of the study was to assess the prevalence of MS in neonates by using the parameters like location, method of delivery, gestational age, and, weight at birth. 500 neonates were enrolled in the study for the evaluation of the prevalence of Mongolian spots. The study design was cross-sectional, observational, and conducted for two and a half years. The neonate's whole skin surface, including the hand palms, scalps and soles, mucous membranes, genitalia, hair, and nails, was inspected in adequate light. The changes were seen (physiological and pathological) over the skin, so the details were reviewed, analyzed, and documented. Photographic records were kept to document the study. Descriptive statistics were analyzed by t-test and Chi-square test and the inferential statistics were analyzed by proportions and Chi-square test. From the 500 neonates, 408 (81.6%) were reported to have Mongolian spots. Based on the site of locations 337 (82.60%) neonates were found with spots maximum on the sacrococcygeal area and rarely on the extremities 4 (0.98%). 221 (54.1%) were found with normal vaginal delivery, and males have more predominance 247 (60%). Based on the gestational age full term was 366 (89.71%), with the birth at a weight of more than 2.5 kg found in 349 (85.54%). The study concluded that the maximum number of neonates had been found with Mongolian spots and it is very common among neonates. This study will enlighten the awareness of the physician to distinguish the other lesions from other cutaneous skin conditions. The only drawbacks of this research study are a smaller sample size and limited study duration. The study of diameter, size, and dimensions of spots are not included. More intervention studies are required to compare MS with other skin conditions and their therapies. Further research is required for the study of the dimensions of marks on the neonate's body.

The role of lumbosacral paraspinal muscle degeneration and low vertebral bone mineral density on distal instrumentation-related problems following long-instrumented spinal fusion for degenerative lumbar scoliosis: a retrospective cohort study.

This study aimed to confirm the role of paraspinal muscle degeneration and low vertebral bone mineral density (vBMD) of the lumbosacral region in the development of distal instrumentation-related problems (DIPs) in degenerative lumbar scoliosis (DLS) patients undergoing long-instrumented spinal fusion. From 2013 to 2019, 125 DLS patients with 24-month follow-up after long-instrumented spinal fusion in Beijing Chao-Yang Hospital were retrospectively recruited and divided into DIP and non-DIP groups. Demographic characteristics, surgical data, and radiographic parameters were statistically compared between the groups. Degeneration of the paraspinal muscle was evaluated using the relative gross cross-sectional area (rGCSA), relative functional cross-sectional area (rFCSA), ratio of the rFCSA to rGCSA, gross muscle-fat index, and functional muscle-fat index of the multifidus (MF), erector spinae (ES), paraspinal extensor muscle (PSE), and psoas major determined by preoperative magnetic resonance imaging (MRI). The vBMD of the lumbosacral region and lower instrumented vertebra (LIV) was assessed using Hounsfield unit (HU) values determined by computed tomography (CT) scans. The DeLong test was performed to select MRI and CT scan variables. Multivariable logistic regression analysis was applied to determine the independent predictive factors of DIPs. The incidence of DIPs was 16.0% (20/105). There were no significant differences in demographic characteristics or surgical data between the groups. The rFCSAs of the MF (65.74±21.51 vs. 92.37±21.68; P<0.001), ES (82.67±21.44 vs. 111.48±24.21; P<0.001) and PSE (144.31±36.12 vs. 208.48±41.57; P<0.001) and the HU values of the lumbosacral region (103.80±22.64 vs.. 132.19±19.17; P<0.001) and LIV (111.70±23.23 vs. 128.69±20.70; P=0.005) were significantly lower in the DIP group. Significantly less preoperative pelvic tilt and greater postoperative lumbosacral lordosis and sagittal vertical axis (SVA) values were observed in the DIP group. The rFCSA of the PSE, the HU value of the lumbosacral region, and the postoperative SVA value were detected as independent predictive factors of DIPs. Lower muscularity of the PSE, a lower vBMD of the lumbosacral region, and postoperative sagittal malalignment were independent predictive factors of DIPs. Surgeons should emphasize the preoperative evaluation of paraspinal muscle and bone mass in DLS patients.

Efficacy of Transforaminal Endoscopic Lumbar Discectomy in Elderly Patients Over 65 Years of Age Compared to Young Adults.

Spine surgery rates are increasing in the elderly population due to social aging, and it is known that prognoses related to surgery are worse for the elderly compared to younger individuals. However, minimally invasive surgery, such as full endoscopic surgery, is considered safe with low complication rates due to minimal damage to surrounding tissues. In this study, we compared outcomes of transforaminal endoscopic lumbar discectomy (TELD) in elderly and younger patients with disc herniation in the lumbosacral region. We retrospectively analyzed the data of 249 patients who underwent TELD at a single center between January 2016 to December 2019, with a minimum follow-up of 3 years. Patients were allocated to 2 groups: a young group aged ≤ 65 years (n = 202) or an elderly group aged > 65 years (n = 47). We evaluated baseline characteristics, clinical outcomes, surgery-related outcomes, radiological outcomes, perioperative complications, and adverse events during the 3-year follow-up period. Baseline characteristics, including age, general condition based on American Society of Anesthesiologist physical status classification grade, age-Charlson Comorbidity Index, and disc degeneration, were worse in elderly group (p < 0.001). However, except for leg pain at 4 weeks after surgery, overall outcomes, including pain improvement, radiological change, operation time, blood loss, and hospital stay, were not different between the 2 groups. Furthermore, the rates of perioperative complications (9 patients [4.46%] in the young group and 3 patients [6.38%] in the elderly group, p = 0.578) and adverse events over the 3-year follow-up period (32 patients [15.84%] in the young group and 9 patients [19.15%] in the elderly group, p = 0.582) were comparable in the 2 groups. Our findings suggest that TELD produces similar outcomes in both elderly and younger patients with a herniated disc in the lumbosacral region. TELD can be considered a safe option for appropriately selected elderly patients.

Comparing clinical outcomes of dogs suffering from degenerative lumbosacral stenosis upon surgical or nonsurgical treatment

PICO question In dogs suffering from degenerative lumbosacral stenosis (DLSS), is surgical treatment more effective than nonsurgical therapy in reducing lumbosacral pain and neurological dysfunction in the long-term? Clinical bottom line Category of research Treatment. Number and type of study designs reviewed Two papers were critically reviewed. They were prospective and retrospective studies. Strength of evidence Weak. Outcomes reported Besides the two studies, there are no other studies currently available that directly compare long-term clinical outcome of patients that have undergone nonsurgical and surgical treatment respectively. In the study comparing clinical outcome of nonsurgical treatment by epidural steroid injection (ESI) and surgical treatment of degenerative lumbosacral stenosis, dogs were classified into clinical severity groups ranging from mild to moderate to severe. Mild cases demonstrated degenerative lumbosacral stenosis (DLSS) compatible clinical signs such as lumbosacral pain, reluctance to climb stairs / jump / raise up, lameness and muscle atrophy but no neurological deficits. Moderate cases presented DLSS compatible clinical signs in combination with neurological deficits such as reduced flexor withdrawal, proprioceptive deficits and nerve root signature. Severe cases demonstrated DLSS compatible clinical signs with more severe neurological deficits such as tail paresis and absent perineal reflex. Clinical outcomes were considered complete if clinical signs had resolved at follow-up consultations, partial if there was substantial but incomplete improvement in clinical signs and failed if the dog did not improve or deteriorated further. Improvements in patient condition were measured in terms of clinical outcome grading which is in relation to the initial clinical severity group assigned to each dog. Improvement after single dose of ESI was seen in 27/32 dogs, with 17/22 (after accounting for four dogs whose owners have refused further treatment, five dogs lost to follow-up after re-check as well as one dog whose owners have opted for repeated ESI instillations) relapsing within 6 months. All 17 of these dogs that suffered a relapse after single ESI subsequently underwent surgical treatment and demonstrated improvement in clinical signs, with a complete response seen in eight dogs and a partial response seen in nine dogs. In the study comparing clinical outcome of conservative treatment of exercise restriction with phenylbutazone administration and surgical treatment of degenerative lumbosacral stenosis, outcomes were classified as good in dogs that regained preoperative activity levels; acceptable in dogs with persistent abnormality or requiring continued medication though otherwise active, and poor in all other cases. Out of 16 dogs treated surgically, 11 were treated by dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, while the other five had additional unilateral facetectomy to decompress the seventh lumbar nerve. Out of the 11 dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, 6/11 (54.5%) of dogs were deemed to have a good outcome, while 3/11 (27.3%) of dogs were deemed to have an acceptable outcome. Out of the five dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc with additional unilateral facetectomy, 3/5 (60%) of dogs were deemed to have an acceptable outcome. The outcome of conservative treatment was deemed good in 8/16 (50%) of dogs in the conservative treatment group. Conclusion There is evidence suggesting that both nonsurgical and surgical treatments can improve clinical outcomes and reduce lower back pain and neurological deficits. However, based on the current limited literature, it cannot be ascertained whether surgical treatments are more effective than nonsurgical treatments in improving long-term clinical outcomes and vice versa. In the study that tested the efficacy of epidural steroid injection, only a single dose of steroids was given in this study, making it a potential reason for the high rate of relapse following nonsurgical treatment. For surgical treatment of DLSS, the type of surgical procedure chosen would also depend on the part of the lumbosacral region which fails and leads to compression. In conclusion, randomised controlled trials that compare different forms of nonsurgical treatment with surgical treatment for dogs with DLSS caused by different underlying factors need to be conducted to properly address the PICO question. How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

(053) Low Intensity Shockwave Therapy in Patients with Vulvas with Sexual Dysfunction

Abstract Introduction High intensity shockwave treatment has been used for kidney stone lithotripsy since the 1980’s; such devices generate an energy flux density (EFD) of approximately 0.9 mJ/mm2. Low intensity shockwave therapy (LiSWT) devices generate approximately one tenth of that EFD, 0.05 – 0.13 mJ/mm2. LiSWT was first used in sexual medicine in 2010 to treat erectile dysfunction (ED). In 2019 we began utilizing LiSWT for patients with vulvas with various sexual dysfunctions (SD). Objective To review our clinical uses of LiSWT as a non-hormonal, non-surgical treatment option for individuals with vulvas with various complaints of SD. Methods We have performed 324 total LiSWT treatment sessions, 1 to 17 total treatments per person, in 77 individuals with vulvas with SD; EFD (0.05 – 0.13 mJ/mm2), shocks (1800 – 4000/treatment), Hz 3, membrane pressure 1. The specific device used in our clinic, Softwave (TRT), is considered non-significant risk for human use by the FDA and cleared for pain amelioration, connective tissue activation, wound healing, and improved blood flow. This device has a parabolic reflective surface. For each underwater spark-gap discharge that generates a shockwave, there actually two shockwaves delivered: a primary unfocused shockwave and a secondary reflected focused shockwave. Each energy wave induces a variety of biologic reactions in tissues resulting from the mechanotransduction contraction/expansion forces produced. Results To date we have identified 4 clinical uses for LiSWT in our patients with vulvas (mean age 39 ± 21 years). Individuals with hormonally-mediated vestibulodynia (n = 12) or entrance dyspareunia associated with genitourinary syndrome of menopause (n = 13) have received a total of 61 (mean 5) and 64 (mean 5) vestibular treatment sessions, respectively. Positive outcomes from a sham-controlled randomized trial have been published for vestibulodynia. Our positive clinical experience in 60% (15/25) mirrors their data. This is especially important because not everyone is willing or able to undergo hormone treatment. Individuals with genito-pelvic dysesthesia from sacral radiculopathy (n = 22) have received 109 (mean 5) treatments directed to their lumbo-sacral region. These patients were either not candidates for spine surgery or continued to experience mild symptoms after spine surgery. LiSWT decreased or eliminated dysesthesia symptoms in 68% (15/22); a key predictor of success was the activation of radiculopathy symptoms (e.g. feet burning) during treatment. Finally, individuals who underwent LiSWT pre-operatively to reduce opioid use after complete vestibulectomy (n = 30) have received 90 (mean 3) vestibular treatments with a 65% reduction in opioid use with such prophylactic treatment. We have observed no serious and 2 transient adverse events, mild discomfort that resolved within several hours. Conclusions For individuals with vulvas with varying complaints of SD, LiSWT is a safe and effective non-hormonal, non-surgical treatment strategy. More research with LiSWT in this population is needed. A potential new clinical use for LiSWT is to manage stress/urge urinary incontinence (SUI) in a non-invasive, non-pharmacologic strategy. Disclosure No

Single surgeon case series of myelomeningocele repairs in a developing world setting: Challenges and lessons

PurposeNeural Tube Defects are the second most common group of birth malformations following congenital heart anomalies, with myelomeningoceles being the most severe manifestation (MMC). They require expedited surgical repair, preferably within 72 ​h of birth. In low- and middle-income countries (LMIC) where resources are limited, timing to MMC repair is not optimal and leads to undesirable outcomes. The purpose of this study was to determine whether a proactive approach in a setting from a LMIC could achieve repair within 72 ​h. MethodsA concerted effort to expedite repair of all neonates referred with a MMC was undertaken from 01 January 2014 to 1 August 2015. A consensus was reached between neonatologists and neurosurgeons that neonates born or admitted with a MMC are referred immediately to surgeons and that repair will be performed within 72 ​h of birth. Hospital records of neonates who had MMC repaired during this period were reviewed for infant characteristics and hospital outcomes. Results24 patients with a MMC were operated upon by the senior author (CP) during the study period. Only 13 of these patients were born at the treating institution and 11 were referred from outside hospitals. Most MMCs were in the lumbosacral region and mean MMC surface area was 19.4 ​cm2. Mean time to repair for the entire series was 13.6 days. Patients born at the treating institution has a mean time to repair of 10.5 days and patients referred from outside had a mean time to repair of 17.3 days. Series wide, only 21% of neonates were operated upon in less than 72 ​h. ConclusionDespite a pro-active commitment to repairing MMCs within 72 ​h for the duration of this series, satisfactory time to repair was not achieved. Late referral, referral from outside hospitals and operating theatre availability were the predominant factors leading to delay in MMC repair. Nevertheless, time to repair in our series was significantly shorter than that reported in MMC repair series based in similar environments. This suggests that even if the gold-standard of a 72-h window cannot be achieved, neonates benefit from much quicker repair when a concerted effort to minimise repair time is employed. This study also highlights the urgent need to address health care constraints in LMIC to improve outcomes for this vulnerable group.

The Case Files

A ruptured dermoid can have many presentations, making it hard to diagnoseFigureFigureA 45-year-old man presented after a sudden transient loss of consciousness followed by excessive crying. He was conscious and oriented upon arrival. He had no fever, and his blood pressure was 130/80 mm Hg, heart rate was 90 bpm, respiratory rate was 20 bpm, oxygen saturation level was 100 percent, and blood sugar level was 103 mg/dL. No neurological deficit was found on examination. The patient had a sinus tract on his lower back at L2-L3. The rest of the exam was normal. The patient had no significant medical history and was not taking any medication. Neuroimaging, CT, and a brain MRI revealed disseminated lipid tissue in the frontal horn of the lateral, third, and fourth ventricles. Similar extra-axial fat intensities were also found in the frontal region and left sylvian, interpeduncular, and right CP angle cisterns. Two differential diagnoses were considered: ruptured dermoid tumor and traumatic pelvic or spinal fracture. Spinal MRI suggested an intramedullary mass lesion with lobulated margin (1.6 cm by 1.1 cm by 6.8 cm) in the conus medullaris and cauda equina, extending from the L1 to L3 vertebrae. The lesion appeared hyperintense on T2W and T1W images, which were suppressed on saturated T1 images. Evidence of intramedullary T1 and T2 hyperintense multiple foci adherent to the dorso-lumbar spinal cord suggested a ruptured dermoid. A dorsal dermal sinus tract at L2 to L3 vertebrae was noted. Rupture of a spinal dermoid cyst into the central spinal canal is rare. An intradural dermoid cyst may rupture with subsequent subarachnoid dissemination of lipid droplets. Dermoid cysts are benign tumor-like lesions comprising approximately one percent of intracranial and spinal tumors and occur slightly more often in men. Their high incidence occurs in the lumbosacral region involving the conus and cauda equina. Upper thoracic (10%) and cervical (5%) lesions are rare. Dermoids are associated with a dermal sinus in 20 percent of cases. The rupture of a dermoid cyst is a well-known phenomenon and can be spontaneous, iatrogenic, or traumatic in origin. A ruptured dermoid may have myriad presentations. Chemical and aseptic meningitis are the most common features after a rupture because of the irritating effects of the disseminated cholesterol debris. The patient may be asymptomatic or experience headache, vomiting, seizures, coma, infarct, and rarely death. A headache might occur because of the compression of adjacent structures, chemical meningitis, or hydrocephalus due to obstruction of cerebrospinal fluid pathways by lipid droplet. The mean age at presentation of such lesions is 40.6, and all cases have been reported in men. Treatment includes steroids, analgesics, antibiotics, and surgical resection of the spinal lesion.

Imaging Features of Intraosseous Schwannoma: A Case Series and Review of the Literature.

To characterize the imaging features of patients with pathologically confirmed intraosseous schwannoma (IOS), institutional pathology and imaging databases were searched for IOS cases over a period of 17 years. A musculoskeletal radiologist evaluated all imaging studies. Additionally, a literature search was performed to identify IOS cases that had imaging findings of at least two modalities. Six patients (one female, five males, mean age of 50 ± 14 years) with IOS were identified, with all lesions localized to the lumbosacral region. Radiographic imaging was available in four patients, while all patients underwent CT and MR imaging. Radiographs depicted lytic lesions, and CT depicted heterogeneous expansile lesions with centrally hypodense areas and peripheral sclerosis. All cases involved extra-osseous extension, producing a mass effect on adjacent soft tissues and nerve roots. On MRI, the neoplasms displayed iso- to- slightly- low signal intensity on T1-weighted images and hyperintense signal intensity on T2-weighted images with heterogeneous enhancement. The literature review resulted in 102 IOS cases, which to the best of our knowledge, is the largest review on IOS, and the imaging findings of the previously published cases were the same as our cases. IOSs are rare benign neoplasms that should be considered in the differential diagnosis of well-defined expansile lytic lesions with sclerotic borders. This is particularly important in middle-aged adults with mandibular, sacral, or vertebral body mass.

MRI characteristics of lumbosacral dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas located in the lumbosacral region are rare and present with nonspecific clinical signs. The purpose of this study was to find out the specific radiologic features of these fistulas. We retrospectively reviewed the clinical and radiological data of 38 patients diagnosed with lumbosacral spinal dural arteriovenous fistulas in our institution from September 2016 to September 2021. All patients underwent time-resolved contrast-enhanced three-dimensional MRA and DSA examinations, and were treated with either endovascular or neurosurgical strategies. Most of the patients (89.5%) had motor or sensory disorders in both lower limbs as the first symptoms. On MRA, the dilated filum terminale vein or radicular vein was seen in 23/30 (76.7%) patients with lumbar spinal dural arteriovenous fistulas and 8/8 (100%) patients with sacral spinal dural arteriovenous fistulas. T2W intramedullary abnormally high signal intensity areas were found in all lumbosacral spinal dural arteriovenous fistula patients, with involvement of the conus present in 35/38 (92.1%) patients. The "missing piece sign" in the intramedullary enhancement area was seen in 29/38 (76.3%) patients. Dilatation of the filum terminale vein or radicular vein is powerful evidence for diagnosis of lumbosacral spinal dural arteriovenous fistulas, especially for sacral spinal dural arteriovenous fistulas. T2W intramedullary hyperintensity in the thoracic spinal cord and conus, and the missing-piece sign could be indicative of lumbosacral spinal dural arteriovenous fistula.

Relationship between Age and Lumbosacral Angle (LSA) of Adult Nigerians: A Cross-sectional Study

Background: The lumbosacral angle (LSA), is a key morphometric parameter important in the management of patients with low back disorders.&#x0D; Aim: The study evaluated the relationship between age and lumbosacral angle of adult Nigerians.&#x0D; Methods: Two hundred and twenty-six (226) radiographs (113 males to 113 females) were obtained from Radiology departments of Federal Medical Centre (FMC), Owerri. Inclusion criteria were, lateral radiographs of lumbosacral region marked above 18 years of ages and only clear X-ray films were used.Using the Ferguson's approach, the lumbosacral angle was measured. All data obtained were expressed both in descriptive and inferential statistics.&#x0D; Results: Both male and female categories showed a progressive increase in lumbosacral angle across age groups, but later decreased in the age group of 60 years and above. The mean lumbosacral angle of male subjects was 35.74° while that of females was 41.46°. There was a significant difference (t = 3.16, p = 0.002) between the lumbosacral angle of male and female categories. However, there was a weak, positive correlation between age and lumbosacral angle of males (r = 0.187) and females (r = 0.392).&#x0D; Conclusion: The males had a lower mean lumbosacral angle compared to the females. Age was significantly correlated with lumbosacral angle in both sexes.

Application of hot medicated fomentation for pain alleviation in non-specific low back pain - A randomized controlled clinical trial

BackgroundNon-specific low back pain is a leading contributor to disease burden and works absenteeism worldwide with a lifetime prevalence of 60–70% in industrialized countries. This clinical study aimed to assess the efficacy of hot fomentation with half-baked medicated bread (khubz) compared to hot water bag fomentation to alleviate pain and disability in non-specific low back pain. MethodsIn this randomized-controlled study, fifty-four patients with low back pain were randomly assigned into two groups to receive either hot fomentation (Takmīd-e-haar) with half-baked medicated bread in the test group or hot water bag fomentation in the control group, on the lumbosacral region daily for 30 min for 15 consecutive days. Patients were assessed statistically using the visual analogue scale (VAS) and Oswestry disability index (ODI) at baseline, 7th and after treatment (15th day). ResultsAfter the intervention, statistically significant improvements (p < 0.001) were observed in VAS and ODI scores in both the groups on the intragroup comparison. The test treatment showed better efficacy in comparison to the control treatment with a mean difference of 1.75 in VAS (p < 0.0001) and 8.20 in ODI (p = 0.001). ConclusionThe tested intervention showed significantly better efficacy in comparison to the hot water bag fomentation probably due to the analgesic (musakkin-i-alam), anti-inflammatory (muḥallil-i-awrām), and demulcent (mulaṭṭif) properties of the ingredients of tested Unani formulation in addition to the effects of heat. It may therefore be concluded that medicated fomentation is an effective, safer, feasible, and less expensive regimen for patients with non-specific low back pain. Trial registrationThe Clinical Trials Registry-India (CTRI/2020/03/024107).