Sacrum Research Articles

Methodology for vNOTES Sacrocolpopexy with Transvaginal Mesh Retroperitonealization and Tensioning

Background: Laparoscopy has the potential of making procedures less invasive with a lower complication profile while being more appealing to patients due to ease of recovery and cosmesis. Sacrocolpopexy has traditionally been performed through the abdominal route with limited reports of transvaginal applications. Methods: Our study aims to provide a step-by-step approach to performing a vNOTES sacrocolpopexy with appropriate tensioning and peritoneal coverage of the mesh used based on both cadaveric and live patient experience. This systematic description of a fully laparoscopic transvaginal apical suspension with mesh attachment to the sacrum being completely retroperitoneal and the mesh retroperitoneal and covered at the conclusion of the case. Results: Successful vNOTES Sacrocolpopexy is performed and reproduced, with transvaginal complete peritoneal coverage and tensioning of the mesh. Total vaginal length (TVL) of 9 cm in both live and cadaveric patients. The steps of the procedure include 1. A vNOTES laparoscopic-assisted vaginal hysterectomy is completed. 2. A 0-Prolene suture is attached longitudinally to the sacral arm of a precut (Y) mesh or any single layer Type I polypropylene mesh piece, placed from the sacral arm to the distal edge of the mesh forming a “U” shape with the bottom of the “U” ultimately attaching to the anterior longitudinal ligament. 3. To begin the SCP procedure after completion of the vaginal hysterectomy, dissection of the presacral mesh attachment site begins by entering the retroperitoneal space, slightly right of midline at the level of the ischial spine, lateral to the rectum and medial to the uterosacral ligament. 4. Once the dissection is completed with appropriate exposure of the anterior longitudinal ligament at the sacral promontory, the sacral mesh is attached to the anterior longitudinal ligament at the S1-2 level, ideally with a tacker under direct visualization. 5. Two sutures, one on each side of the tunnel, are placed on the cephalad edge of the sacral peritoneal incision and labeled. After removing the Gelport, two more absorbable sutures are attached to the anterior peritoneum of the anterior vaginal wall in the proximity of the bladder, around 3 cm on each side of the midline. These peritoneal sutures in each of the above two steps will later be tied together to help cover the arms of the mesh. 6. Before mesh arm attachment, each area on the anterior and posterior vaginal walls is dissected off respective tissue (bladder and perineal body/rectovaginal fascia) and then everted for mesh attachment. 7. Both anterior and posterior mesh pieces are sutured to their respective vaginal walls with six interrupted sutures. Each mesh arm will have several centimeters of mesh freely hanging off both anterior and posterior cuff edges. These edges can be trimmed to 2 cm past the vaginal cuff edge. 8. All three pieces of mesh are stacked together and serially threaded from anterior mesh to posterior mesh, ensuring each mesh piece remains aligned (Figure 1). Each U suture is then passed through the free ends of the anterior and posterior mesh pieces and then secured with a hemostat. The cut edges of the suture can either be aligned at the back of the posterior arm to permit retroperitonealization of the knot or placement at the vaginal apex abutting the vaginal cuff. 9. Peritoneal closure is achieved by tying a posterior tunnel suture to each respective anterior vaginal wall suture at each lateral edge of the tunnel incision. 10. The vaginal cuff closure begins with a Vicryl suture anchored at the patient’s right forniceal edge running it to midline while anchoring another suture at the left forniceal edge to permit the surgeon to tension the vaginal apex appropriately. 11. Mesh tensioning is achieved by placing a single digit through the remaining space left in the tunnel incision. A knot using the Prolene suture securing the overlapping mesh is tied extracorporeally and pushed through the vaginal cuff to mobilize the mesh crux cephalad, thus elevating the vaginal apex towards the sacrum. The elevation of this knot guides the vaginal length. 12. The remainder of the vaginal cuff is then closed while avoiding incorporation of the mesh into the suture line (the ideal distance from mesh Y-junction to cuff is 1-2cm). Conclusion: By describing an innovative and reproducible technique to perform vNOTES sacrocolpopexy based on cadaveric and live patient experience, we successfully demonstrate how to perform a laparoscopic transvaginal apical suspension with mesh attachment to the sacrum through retroperitoneal placement. The vNOTES approach for sacrocolpopexy may offer a viable alternative to the transabdominal approach for candidates with difficult transabdominal access while avoiding trocar injuries and reducing surgical costs.

Prenatal Management of High Risk Fetal Sacrococcygeal Teratoma

Introduction: Fetal sacrococcygeal teratomas (SCGT), the most common fetal neoplasm diagnosed in fetuses, are a rare condition with an estimated incidence of 1 in 40,0000 live births. Fetal SCGT is usually suspected when characteristic findings are seen on ultrasound such as a mass that is cystic and/or solid and is located in the sacral region. MRI may also be used to more accurately characterize the tumor and to help distinguish between SCGTs and distal neural tube defects like sacral meningomyelocele. Despite advances in ultrasound and MRI, only approximately 50% are diagnosed prenatally. The detection of fetal SCGT is important because it changes pregnancy monitoring and management as it is associated with fetal hydrops, intrauterine death, polyhydramnios, mirror syndrome, and mortality rates as high as 43%. Once an SCGT has been identified, serial ultrasound evaluation of the fetus, placenta, and SCGT is important to identify early signs of fetal hydrops, fetal anemia, or cardiac failure and to intervene as appropriate. Case Report: A 40-year-old G5P4004 was referred to Maternal Fetal Medicine (MFM) due to findings of a 1 cm mass near the fetal bladder on first trimester ultrasound. She had a level II ultrasound performed by MFM at 16.2 weeks where a 3.6 x 2.3 x 2.6 cm mass was identified. This mass was adjacent to the sacrococcygeal region. Due to its location and characteristic appearance, with both cystic and solid components with high vascularity, a fetal sacrococcygeal teratoma was suspected. There were no signs of hydrops or fetal anemia. At this time, the recommendation for management was: ultrasounds every 2 weeks to assess for hydrops and fetal anemia, growth ultrasound every 4 weeks, an echocardiogram by pediatric cardiology at 22-24 weeks, a fetal MRI at 28 weeks, and delivery between 37-39 weeks or earlier pending clinical course. At 24.2 weeks, she developed polyhydramnios with a maximum vertical pocket (MVP) of 10.5 cm. She had also failed her 1-hour glucose tolerance test with a value of 287 mg/dL. Due to the new finding of polyhydramnios and diagnosis of gestational diabetes, her monitoring was increased to weekly, with biophysical profile (BPP) starting at 28 weeks and weekly nonstress tests (NST) at 32 weeks. A fetal MRI was performed at 26.4 weeks and showed a large lesion extending off the sacrococcygeal region measuring 9.6 x 6.3 x 7.7 cm that was composed of both solid and cystic components. By 32.2 weeks, she developed severe polyhydramnios with an AFI of 36.0 cm and accelerated fetal growth due to an AC > 99th percentile. The last ultrasound she had at 34.2 weeks the SCGT measured 17.7 x 13.3 x 13.6 cm and severe polyhydramnios persisted. The patient went into preterm labor at 35.2 weeks and had a cesarean section due to known SCGT measuring greater than 5 cm. Immediately after delivery, the neonate was evaluated by the neonatal team and transferred to the Neonatal Intensive Care Unit. The infant had surgical resection of the mass and will have tumor markers, AFP and LDH, monitored for development of recurrent immature or mature teratoma. The pathology report confirmed the diagnosis for benign sacrococcygeal teratoma. Discussion: Failure to diagnose a fetal sacrococcygeal teratoma has potentially catastrophic consequences for the fetus and mother. Maternal complications include hyperemesis, preeclampsia, mirror syndrome, preterm labor, and HELLP syndrome. Significant obstetric complications can be as high as 81%. Intrauterine fetal complications include fetal hydrops from high-output failure, fetal anemia, intratumoral hemorrhage, polyhydramnios, genitourinary obstruction leaking to hydronephrosis and or hydroureter. SCGT size >10 cm or tumor with rapid growth has > 50% perinatal mortality. Tumor characteristics associated with higher mortality rates are early diagnosis, solid components, high vascularity, tumor size > 10 cm, and rapid growth > 150 cm3/week. Another way to risk stratify these patients is by calculating a tumor volume to fetal weight ratio (TFR), which if > 0.12 at < 24 weeks is predictive of an overall poor prognosis. When comparing this case to literature review of sacrococcygeal teratomas, the patient’s fetal SCGT would be classified as high risk of mortality due to the tumor characteristics of early diagnosis, TFR at 20 weeks being 0.16, large size, rapid growth, and pronounced vascularity. Overall, in this high risk case of SCGT, the close follow up and evidence-based management with utilization and collaboration of a multidisciplinary team including Maternal Fetal Medicine, NICU, and Pediatric Surgery in a tertiary center resulted in a successful outcome.

Prenatal Management of High Risk Fetal Sacrococcygeal Teratoma

Introduction: Fetal sacrococcygeal teratomas (SCGT), the most common fetal neoplasm diagnosed in fetuses, are a rare condition with an estimated incidence of 1 in 40,0000 live births. Fetal SCGT is usually suspected when characteristic findings are seen on ultrasound such as a mass that is cystic and/or solid and is located in the sacral region. MRI may also be used to more accurately characterize the tumor and to help distinguish between SCGTs and distal neural tube defects like sacral meningomyelocele. Despite advances in ultrasound and MRI, only approximately 50% are diagnosed prenatally. The detection of fetal SCGT is important because it changes pregnancy monitoring and management as it is associated with fetal hydrops, intrauterine death, polyhydramnios, mirror syndrome, and mortality rates as high as 43%. Once an SCGT has been identified, serial ultrasound evaluation of the fetus, placenta, and SCGT is important to identify early signs of fetal hydrops, fetal anemia, or cardiac failure and to intervene as appropriate. Case Report: A 40-year-old G5P4004 was referred to Maternal Fetal Medicine (MFM) due to findings of a 1 cm mass near the fetal bladder on first trimester ultrasound. She had a level II ultrasound performed by MFM at 16.2 weeks where a 3.6 x 2.3 x 2.6 cm mass was identified. This mass was adjacent to the sacrococcygeal region. Due to its location and characteristic appearance, with both cystic and solid components with high vascularity, a fetal sacrococcygeal teratoma was suspected. There were no signs of hydrops or fetal anemia. At this time, the recommendation for management was: ultrasounds every 2 weeks to assess for hydrops and fetal anemia, growth ultrasound every 4 weeks, an echocardiogram by pediatric cardiology at 22-24 weeks, a fetal MRI at 28 weeks, and delivery between 37-39 weeks or earlier pending clinical course. At 24.2 weeks, she developed polyhydramnios with a maximum vertical pocket (MVP) of 10.5 cm. She had also failed her 1-hour glucose tolerance test with a value of 287 mg/dL. Due to the new finding of polyhydramnios and diagnosis of gestational diabetes, her monitoring was increased to weekly, with biophysical profile (BPP) starting at 28 weeks and weekly nonstress tests (NST) at 32 weeks. A fetal MRI was performed at 26.4 weeks and showed a large lesion extending off the sacrococcygeal region measuring 9.6 x 6.3 x 7.7 cm that was composed of both solid and cystic components. By 32.2 weeks, she developed severe polyhydramnios with an AFI of 36.0 cm and accelerated fetal growth due to an AC > 99th percentile. The last ultrasound she had at 34.2 weeks the SCGT measured 17.7 x 13.3 x 13.6 cm and severe polyhydramnios persisted. The patient went into preterm labor at 35.2 weeks and had a cesarean section due to known SCGT measuring greater than 5 cm. Immediately after delivery, the neonate was evaluated by the neonatal team and transferred to the Neonatal Intensive Care Unit. The infant had surgical resection of the mass and will have tumor markers, AFP and LDH, monitored for development of recurrent immature or mature teratoma. The pathology report confirmed the diagnosis for benign sacrococcygeal teratoma. Discussion: Failure to diagnose a fetal sacrococcygeal teratoma has potentially catastrophic consequences for the fetus and mother. Maternal complications include hyperemesis, preeclampsia, mirror syndrome, preterm labor, and HELLP syndrome. Significant obstetric complications can be as high as 81%. Intrauterine fetal complications include fetal hydrops from high-output failure, fetal anemia, intratumoral hemorrhage, polyhydramnios, genitourinary obstruction leaking to hydronephrosis and or hydroureter. SCGT size >10 cm or tumor with rapid growth has > 50% perinatal mortality. Tumor characteristics associated with higher mortality rates are early diagnosis, solid components, high vascularity, tumor size > 10 cm, and rapid growth > 150 cm3/week. Another way to risk stratify these patients is by calculating a tumor volume to fetal weight ratio (TFR), which if > 0.12 at < 24 weeks is predictive of an overall poor prognosis. When comparing this case to literature review of sacrococcygeal teratomas, the patient’s fetal SCGT would be classified as high risk of mortality due to the tumor characteristics of early diagnosis, TFR at 20 weeks being 0.16, large size, rapid growth, and pronounced vascularity. Overall, in this high risk case of SCGT, the close follow up and evidence-based management with utilization and collaboration of a multidisciplinary team including Maternal Fetal Medicine, NICU, and Pediatric Surgery in a tertiary center resulted in a successful outcome.

Management and Delivery of a Patient with Maternal Myelomeningocele: A Case Report

Objective: To report and discuss the pregnancy course and delivery of a patient with maternal myelomeningocele at term Background: Spina bifida is a congenital malformation which results from incomplete closure of the neural tube. Open neural tube defects (NTD) comprise 80% of all NTDs. The most common open NTD is myelomeningocele (MMC), a form of spina bifida characterized by herniation of both the meninges and spinal cord. The incidence rate of MMC is approximately 1/1,000 live births worldwide, and is inversely related to socioeconomic status. There is a paucity of data on pregnant women with spina bifida, however a study by Shepard et al. investigated deliveries among 10,000 women with spina bifida and 42 million women without. This study revealed that women with spina bifida were significantly more likely to be delivered via cesarean section, even when vaginal delivery was possible. Also, pregnancy rates in spina bifida patients have risen over time. Case Description: A 29-year-old gravida 1 female at 12 weeks gestation presented to the Maternal Fetal Medicine (MFM) clinic due to maternal MMC. Past medical history was significant for MMC, Chiari malformation type II, neurogenic bowel, and neurogenic bladder. Past surgical history was significant for MMC repair, ventriculoperitoneal shunt, spine-to-abdomen shunt, cervical spine fusion, spinal cord untethering, and club foot correction. Patient ambulated using a walker. Noninvasive prenatal testing was low-risk. The alpha-fetoprotein was unremarkable at 22 ng/ml. Ultrasound revealed unilateral fetal pyelectasis. Fetal echocardiogram showed normal anatomy and function. The patient was admitted for 4 days at 33 weeks for a unilateral vulvar infection and hematoma that developed from repeated self-catheterization. The patient was admitted out of precaution due to past history of labial Fournier’s gangrene. Wound cultures grew prevotella bivia. Infectious disease recommended outpatient oral antibiotics at discharge. Anesthesiology recommended maternal MRI prior to delivery planning. MRI showed lumbar lordosis and severe canal compromise in the lumbosacral region. The low-lying conus terminated at L3-L4. Cauda equina nerve roots extended to the sacral region. Morphology of the sacrum and coccyx was abnormal, consistent with MMC. Imaging determined epidural and spinal anesthesia carried a high likelihood of analgesic failure from scar tissue due to prior surgeries. The patient ultimately agreed to general anesthesia. A primary low-transverse cesarean section was performed at 39 weeks 0 days. The baby was delivered without delayed cord clamping and had 1- and 5-minute APGAR scores of 6 and 9. Dense adhesions were present throughout the abdomen, which prevented uterine exteriorization during hysterotomy repair. The remainder of the surgery was uncomplicated and indwelling foley was kept in place postpartum. At 6-week postpartum visit, patient was fully healed and had resumed self-catheterization. Discussion: Pregnant women with spina bifida require complex multi-disciplinary co-management. This patient received care from MFM, neurology, urology, anesthesiology, infectious disease, and neurosurgery. Currently, there are no universally established guidelines on the management of pregnant women with spina bifida, but general principles of management exist. In the pre-conception period, it is recommended that patients at high-risk for fetal spina bifida, including type 1 diabetics, take 4mg of folate daily. High-risk patients should take folate for at least 3 months prior to conception and up until 12 weeks’ gestation. Since 9-12% of this population is affected by epilepsy, optimizing seizure medications is prudent. Lamotrigine or Carbamazepine monotherapy is preferred, as they pose the least risk of congenital malformations. In the antepartum period, providers should anticipate treating common comorbidities. Bladder dysfunction includes either hyper-reflexive or areflexive bladders. Intermittent self-catheterization is a viable option for those with incomplete bladder emptying. Pregnant patients with ventriculoperitoneal shunts are susceptible to displacement from the gravid uterus. Since limited mobility is prevalent in this population, risk assessments for venous thromboembolism should be completed, and prophylactic anticoagulation may be considered. Vaginal delivery is possible in some patients. However, epidural or spinal anesthesia can increase the risk of spinal cord injury in those with tethered cords or prior surgery. Patients with limited mobility may require cesarean section due to inability to position for labor. In conclusion, MMC is rarely encountered in obstetrical contexts but is becoming increasingly more commonplace. MMC requires co-management by multiple specialties to surveil and optimize common comorbidities. In this case, the patient’s pregnancy course was mainly complicated by her pre-existing neurogenic bladder and resulting vulvar wound secondary to self-catheterization. For MMC patients who are interested in pregnancy, preparations should be started in the pre-conception period, with close monitoring throughout the antepartum period to follow. Currently, there are generally accepted guidelines for managing MMC patients in pregnancy, but there is a lack of global standardization. The development of standardized treatment guidelines may be possible as more of these cases are discussed and appear in the literature.

The radio anatomical arrangement of nerve roots at L3 level in cauda equina sac is it affected by diseases?

An observational study to discover the common conditions affecting the lumbosacral region that may affect lumbosacral position and tension. All the patients, underwent MRI exaamination (magnetic resonance imaging) in the supine position, were examined by the same consultant radiologist. The article was revised by the institutional ethical approval committee. The position of the nerve roots was observed, and the number of nerve roots was calculated anterior to a line passing between the mid-transvers process of L3(third lumbar vertebra). The number of nerve roots ahead of this line was calculated by the radiologist at the level of the right intervertebral foramen and at the left one. This procedure was applied to the normal group, and 5 common pathological diseases were repeated including single-level lumbar disc prolapse, multiple-disc prolapse, multiple bulge, spinal stenosis and spondylolisthesis (at the level of L45 (fourth to fifth lumbar vertebrae) or L5S1 (fifth lumbar to first sacral vertebrae) being outside the study area, i.e., L3). We noticed significant difference in the number of the nerve roots between the cases with herniated discs, spinal stenosis, and spondylolisthesis with the normal group and the significance was in ascending increment in significance being the highest in cases with spondylolisthesis, and even in the groups of other pathologies which are statistically not significant, we noticed that the significance is proportional to the severity of the disease being the least in single level cases (p 0.427), to be more significant on cases with multiple prolapses(p 0.319) to be more in cases with multiple bulges to start to be statistically significant in herniated, higher significance in cases with spinal stenosis to be the highest in cases with spondylolisthesis.

Evaluation of Symmetry of Ventrodorsal Pelvic Radiographs in Dogs; A Retrospective Study

Pelvic radiographs in dogs have been used for assessments of pelvic bone, hip joint, and sacral bone in orthopaedic examinations. Thus, symmetric radiographs must be a goal to minimise medical errors. Despite the importance of symmetric radiographs, ventrodorsally pelvic radiographs are routinely evaluated using the symmetric appearance of the obturator foramen and wing of the ilium. This retrospective study was performed to evaluate the symmetry of pelvic radiographs in dogs. For this purpose, 100 pelvic radiographs were reevaluated by linear, area, and circumference measurements. The differences in percentages were remarkable for width and area values for both the ilium and obturator foramen between the left and right sides. In terms of the difference in the percentage of iliac wing width, two-thirds of radiographs showed asymmetry up to 20% and higher in the remaining one-third of radiographs. The findings of this research indicate that completely symmetrical positioning on pelvic radiographs is often not obtained.

Management and Delivery of a Patient with Maternal Myelomeningocele: A Case Report

Objective: To report and discuss the pregnancy course and delivery of a patient with maternal myelomeningocele at term Background: Spina bifida is a congenital malformation which results from incomplete closure of the neural tube. Open neural tube defects (NTD) comprise 80% of all NTDs. The most common open NTD is myelomeningocele (MMC), a form of spina bifida characterized by herniation of both the meninges and spinal cord. The incidence rate of MMC is approximately 1/1,000 live births worldwide, and is inversely related to socioeconomic status. There is a paucity of data on pregnant women with spina bifida, however a study by Shepard et al. investigated deliveries among 10,000 women with spina bifida and 42 million women without. This study revealed that women with spina bifida were significantly more likely to be delivered via cesarean section, even when vaginal delivery was possible. Also, pregnancy rates in spina bifida patients have risen over time. Case Description: A 29-year-old gravida 1 female at 12 weeks gestation presented to the Maternal Fetal Medicine (MFM) clinic due to maternal MMC. Past medical history was significant for MMC, Chiari malformation type II, neurogenic bowel, and neurogenic bladder. Past surgical history was significant for MMC repair, ventriculoperitoneal shunt, spine-to-abdomen shunt, cervical spine fusion, spinal cord untethering, and club foot correction. Patient ambulated using a walker. Noninvasive prenatal testing was low-risk. The alpha-fetoprotein was unremarkable at 22 ng/ml. Ultrasound revealed unilateral fetal pyelectasis. Fetal echocardiogram showed normal anatomy and function. The patient was admitted for 4 days at 33 weeks for a unilateral vulvar infection and hematoma that developed from repeated self-catheterization. The patient was admitted out of precaution due to past history of labial Fournier’s gangrene. Wound cultures grew prevotella bivia. Infectious disease recommended outpatient oral antibiotics at discharge. Anesthesiology recommended maternal MRI prior to delivery planning. MRI showed lumbar lordosis and severe canal compromise in the lumbosacral region. The low-lying conus terminated at L3-L4. Cauda equina nerve roots extended to the sacral region. Morphology of the sacrum and coccyx was abnormal, consistent with MMC. Imaging determined epidural and spinal anesthesia carried a high likelihood of analgesic failure from scar tissue due to prior surgeries. The patient ultimately agreed to general anesthesia. A primary low-transverse cesarean section was performed at 39 weeks 0 days. The baby was delivered without delayed cord clamping and had 1- and 5-minute APGAR scores of 6 and 9. Dense adhesions were present throughout the abdomen, which prevented uterine exteriorization during hysterotomy repair. The remainder of the surgery was uncomplicated and indwelling foley was kept in place postpartum. At 6-week postpartum visit, patient was fully healed and had resumed self-catheterization. Discussion: Pregnant women with spina bifida require complex multi-disciplinary co-management. This patient received care from MFM, neurology, urology, anesthesiology, infectious disease, and neurosurgery. Currently, there are no universally established guidelines on the management of pregnant women with spina bifida, but general principles of management exist. In the pre-conception period, it is recommended that patients at high-risk for fetal spina bifida, including type 1 diabetics, take 4mg of folate daily. High-risk patients should take folate for at least 3 months prior to conception and up until 12 weeks’ gestation. Since 9-12% of this population is affected by epilepsy, optimizing seizure medications is prudent. Lamotrigine or Carbamazepine monotherapy is preferred, as they pose the least risk of congenital malformations. In the antepartum period, providers should anticipate treating common comorbidities. Bladder dysfunction includes either hyper-reflexive or areflexive bladders. Intermittent self-catheterization is a viable option for those with incomplete bladder emptying. Pregnant patients with ventriculoperitoneal shunts are susceptible to displacement from the gravid uterus. Since limited mobility is prevalent in this population, risk assessments for venous thromboembolism should be completed, and prophylactic anticoagulation may be considered. Vaginal delivery is possible in some patients. However, epidural or spinal anesthesia can increase the risk of spinal cord injury in those with tethered cords or prior surgery. Patients with limited mobility may require cesarean section due to inability to position for labor. In conclusion, MMC is rarely encountered in obstetrical contexts but is becoming increasingly more commonplace. MMC requires co-management by multiple specialties to surveil and optimize common comorbidities. In this case, the patient’s pregnancy course was mainly complicated by her pre-existing neurogenic bladder and resulting vulvar wound secondary to self-catheterization. For MMC patients who are interested in pregnancy, preparations should be started in the pre-conception period, with close monitoring throughout the antepartum period to follow. Currently, there are generally accepted guidelines for managing MMC patients in pregnancy, but there is a lack of global standardization. The development of standardized treatment guidelines may be possible as more of these cases are discussed and appear in the literature

Effects of applying high-pass filtering in pelvimetry with Martius images.

The aim of this study is to investigate whether the results of pelvimetry using original radiographic Martius images and the same images with high-pass filtering applied ("edge images") would be consistent. A total of 30 primagravidas were included in this study. Three obstetricians independently measured the anteroposterior and transverse diameters of the pelvic inlet in the original and the edge images, recording the x- and y-coordinates of the four endpoints. A Wilcoxon signed rank sum test was performed on the coordinate data to evaluate differences between the original and edge images. In the analysis of all coordinate data, statistically significant differences were found in both x- and y-coordinates of the sacral promontory point (SPP). In the y-coordinate of the SPP, a statistically significant difference was found in 9 of 30 pairs of images, and in all 9 the anteroposterior diameter was shorter in the edge images compared to the original images due to the more caudal placement of the SPP. The coordinates of the SPP on original radiographs and their edge images were not consistent in pelvimetry using Martius images. Our results suggest that improved image contrast will allow obstetricians to better assess pelvic narrowing and cephalopelvic disproportion and even reduce radiographic dose, thereby reducing risks for pregnant women and their fetuses.

Comparing immobilisation devices in gynaecological external beam radiotherapy: improving inter-fraction reproducibility of pelvic tilt.

The aim was to determine which immobilisation device improved inter-fraction reproducibly of pelvic tilt and required the least pre-treatment setup and planning interventions. Sixteen patients were retrospectively reviewed, eight immobilised using the BodyFIX system (BodyFIX®, Elekta, Stockholm, Sweden) and eight using the Butterfly Board (BB) (Bionix Radiation Therapy, Toledo, OH, USA). The daily pre-treatment images were reviewed to assess setup variations between each patient and groups for pelvic tilt, pubic symphysis, sacral promontory and the fifth lumbar spine (L5). Compared with the planning CT, pelvic tilt for most patients was within ±2° using the BodyFIX and ± 4° for the BB. The Butterfly Board had a slightly higher variance both for patient-to-patient (standard deviation of the systematic error) and day-to-day error (standard deviation of the random error). Variance in position between individual patients and the two stabilisation devices were minimal in the anterior-posterior (AP) and superior-inferior (SI) direction for the pubic symphysis, sacral promontory and L5 spine. Re-imaged fractions due to pelvic tilt reduced by about half when BodyFIX was used (39.1% BB, 19.4% BodyFIX). One patient treated with the BB required a re-scan for pelvic tilt. Three patients required a re-scan for body contour variations (two using BodyFIX and one with the BB). BodyFIX resulted in a more accurate inter-fraction setup and efficient treatment and is used as the standard stabilisation for gynaecological patients at our centre. It reduced the pelvic tilt variance and reduced the need for re-imaging pre-treatment by half.

Accuracy and safety of freehand vs. end-on fluoroscopic guided drill-hole placement in canine cadaveric thoracic, lumbar and sacral vertebrae

Accuracy and safety of freehand vs. end-on fluoroscopic guided drill-hole placement in canine cadaveric thoracic, lumbar and sacral vertebrae

Comparison of Traumatic Spinal Fracture Patterns Between Motorcyclists and Occupants of Other Nonheavy Motor Vehicles: A Report from the National Spinal Cord and Column Injury Registry of Iran

ObjectivesTo compare traumatic spinal injury patterns between motorcyclists and occupants of other non-heavy motor vehicles using data from the National Spinal Cord and Column Injury Registry of Iran (NSCIR-IR). MethodsAll drivers/riders and passengers of motorcycles, cars, pick-up trucks, and vans registered between January 2017 to July 2023, met the inclusion criteria for the present study. The logistic regression models were used to compare the patterns of vertebral fracture between the two groups. Results1726 spinal fracture patients were identified, 385 (22.3%) motorcyclists and 1341 (77.7%) car occupants with mean ages 33.2±14.3 and 36.1±13.6 years, respectively (P<0.001). Only 45 (11.7%) motorcyclists used helmets, whereas 856 (63.8%) car occupants used seat belts (P<0.001). The average numbers of fractured vertebrae were 3.9±1.4 and 3.7±1.1 among car occupants and motorcyclists, respectively (P=0.004). The proportions of motorcyclists and car occupants with injuries in each spinal region are as follows: lumbar (50.5% of motorcyclists vs. 40.4% of car occupants; P=0.003), thoracic (39.2% vs. 30.9%; P=0.01), cervical (24.3% vs. 37.0%; P<0.001) and sacral (1.3% vs. 7.5%; P<0.001). The AO Spine type C injuries were present in 6.1% of motorcyclists and 10.1% of car occupants (P=0.03). ConclusionMotorcyclists were younger, less educated, had a higher proportion of males, and less commonly used safety devices than car occupants. The most commonly fractured spine region among both groups was the lumbar region. The cervical and sacral vertebrae fractures were significantly more common in car occupants, whereas the thoracic and lumbar vertebrae fractures were significantly more common in motorcyclists.

Reconstructive Options for Pressure Ulcers in Pediatric Patients.

Pressure ulcers pose significant challenges in terms of treatment, often exhibiting a low success rate and a propensity for recurrence. Children with neurological impairments such as myelomeningocele and those with spinal injuries are particularly vulnerable to developing pressure ulcers. Despite advancements, achieving successful reconstruction remains a formidable task. Common sites prone to pressure ulcer formation include the sacral and ischial regions, as well as areas over bony prominences. Additionally, pressure ulcers attributable to medical devices facilitating ambulation are observed. While many pressure sores resolve spontaneously, conservative management may prove ineffective for some, especially in cases of stage 3 and 4 ulcers, necessitating surgical intervention. Various surgical techniques are employed for the treatment of decubitus ulcers, yet there exists no universally accepted gold standard for their management. This paper presents our institutional experience in this domain, highlighting differences in surgical approaches, treatment outcomes, complication rates, and long-term follow-up. This study involved a retrospective analysis of medical records from 11 children, ranging in age from 10 to 17 years, who presented with extensive pressure ulcers that were unresponsive to conservative treatment measures. Data collection spanned from February 2017 to June 2022. The pressure ulcers affected various anatomical regions, including the ischial area (5/11 patients), sacral region (3/11 patients), lower limb (1/11 patients), elbow (1/11 patients), and perineal area (1/11 patients). Surgical intervention was the chosen approach for all cases, employing techniques such as reconstructive surgery utilizing perforator, pediculated flaps, and locoregional flaps. Eleven patients with sore ulcers (stage 3 and 4) were treated surgically. We present our experience of using surgical methods, including pedicled anterolateral flaps, pedicled gracilis musculocutaneous flaps, propeller flaps and locoregional flaps. In some cases, surgery was performed after 60 days of hospitalization or ten years after ulcer occurrence. We reviewed the length of hospital stay, surgical management and patient satisfaction. Patients were followed up to 5 years post-surgery. All flaps survived except for one flap where partial necrosis was observed. The recurrence rate was 9.01% (1/11). One patient underwent another surgery. The general outcome was satisfactory. Conclusions: Our findings underscore the efficacy of flap reconstruction surgical techniques in the management of pressure ulcers among pediatric patients. Based on our experience and the outcomes observed, we advocate for considering reconstructive surgery as a viable therapeutic option early in the treatment course, particularly for stage 3 and 4 ulcers. This approach not only addresses the immediate needs of patients but also holds promise for long-term wound healing and prevention of recurrence.

Is there a relationship between low back pain and ligamentum flavum hypertrophy?

A condition known as ligamentum flavum (LF) hypertrophy occurs when the ligamentum flavum (LF) swells as a result of pressures applied to the spine. Among the elderly population, lumbar spinal stenosis is a major cause of pain and disabilities. Numerous studies indicate that lumbar spinal stenosis etiology involves the ligamentum flavum in a major way. This study looks into the relationship between low back pain and ligamentum flavum thickening. The imaging tests and case histories of all patients with low back pain who had consecutive magnetic resonance imaging exams performed at the Prince Sattam University and King Khalid hospitals in Al Kharj City will serve as the basis for this retrospective observational study. A radiologist utilized the Pfirrmann grading system, which is based on spinal levels starting from the first lumbar to the first sacral vertebrae, to measure the thickness of the ligamentum flavum in all cases who underwent magnetic resonance imaging (MRI). A correlation between age, hypertrophy of LF, and low back pain was investigated. There were 79 participants in the study, ages ranging from 21 to 82, 49 of which were men. The patients' average age was 54 years, and 62% of them were men. We found no appreciable variations in LF thickness according to gender. At the L4-L5 and L5-S1 levels, the left LF was noticeably thicker than the right. Moreover, there was a significant difference (p < 0.05) in the bilateral LF thicknesses at L5-S1 compared to the comparable sides at L4-L5. By evaluating the thickness of LF on magnetic resonance images, we discovered that it may be closely associated with the etiology of pain processes in the spine.

Bilateral stringhalt associated with Hypochaeris radicata in Uruguayan horses

We reported thirteen cases of bilateral stringhalt associated with Hypochaeris radicata that occurred in horses in Uruguay during a severe drought in the summer of 2023. All horses were affected chronically and progressively by bilateral hyperflexion of hindlimbs. In two severely affected horses, the main histological lesions included neuronal chromatolysis and axonal spheroids in the ventral gray horn in the lumbar and sacral spinal cord and axonal degeneration and digestion chambers in ventral roots fibers and long peripheral nerves. We suggest that in addition to injuries to peripheral nerves, lesions in the spinal cord play an important role in the clinical signs of stringhalt in horses.

Sacrococcygeal Tumor – A Rare Case Report

Sacrococcygeal teratoma (SCT) is a rare congenital tumor primarily affecting infants, with a prevalence of approximately 1 in 35,000 live births. These tumors, often detected either prenatally or shortly after birth, originate from germ cells and typically occur at the base of the coccyx. Despite their benign nature, SCTs can pose significant risks to fetal and maternal health, necessitating careful management and monitoring. A 32-year-old primiparous woman presented to Siak Regional Hospital at 36 weeks of gestation with complaints of uterine contractions and bloody mucus discharge from the birth canal. A physical examination revealed a palpable mass in the uterine fundus and pubic symphysis. Ultrasonography confirmed the presence of a fetal SCT with a solid mass measuring 6.2 x 8.1 x 7.3 cm in the sacral region, and a cesarean section was performed. The infant, a baby girl, was born with a birth weight of 2150 grams and an Apgar score of 3/4. Congenital abnormalities were observed in the form of a solid mass around the sacrum, indicative of SCT. SCT poses challenges in prenatal diagnosis, management, and prognosis. Prompt recognition and multidisciplinary management are essential for optimizing outcomes. Further research is needed to enhance understanding and improve therapeutic strategies for this rare congenital anomaly. SCT is a rare congenital anomaly that requires early diagnosis. Thorough examination with ultrasonography is essential to rule out other congenital anomaly, and predict prognosis.

Preoperative and follow-up variations of psoas major muscle are related to S1 screw loosening in patients with degenerative lumbar spinal stenosis

BackgroundIt was reported the paraspinal muscle played an important role in spinal stability. The preoperative paraspinal muscle was related to S1 screw loosening. But the relationship between preoperative and postoperative change of psoas major muscle (PS) and S1 pedicle screw loosening in degenerative lumbar spinal stenosis (DLSS) patients has not been reported. This study investigated the effects of preoperative and follow-up variations in the psoas major muscle (PS) on the first sacral vertebra (S1) screw loosening in patients with DLSS.Methods212 patients with DLSS who underwent lumbar surgery were included. The patients were divided into the S1 screw loosening group and the S1 screw non-loosening group. Muscle parameters were measured preoperatively and at last follow-up magnetic resonance imaging. A logistic regression analysis was performed to investigate the risk factors for S1 screw loosening.ResultsThe S1 screw loosening rate was 36.32% (77/212). The relative total cross-sectional areas and relative functional cross-sectional areas (rfCSAs) of the PS at L2–S1 were significantly higher after surgery. The increased rfCSA values of the PS at L3–S1 in the S1 screw non-loosening group were significantly higher than those in the S1 screw loosening group. The regression analysis showed male, lower CT value of L1 and longer segment fusion were independent risk factors for S1 screw loosening, and postoperative hypertrophy of the PS was a protective factor for S1 screw loosening.ConclusionsCompared to the preoperative muscle, the PS size increased and fatty infiltration decreased after surgery from L2–3 to L5–S1 in patients with DLSS after short-segment lumbar fusion surgery. Postoperative hypertrophy of the PS might be considered as a protective factor for S1 screw loosening. MRI morphometric parameters and postoperative selected exercise of PS for DLSS patients after posterior lumbar fusion surgery might contribute to improvement of surgical outcome.

Limberg Transpositional Fasciocutaneous Flap in Sacrococcygeal Pilonidal Sinus Disease (SPSD): A Case Series.

Introduction Among young male adults, sacrococcygeal pilonidal sinus disease (SPSD) is a prevalent condition. There are several possibilities for treatment, including both conservative and surgical methods. Medical supervision or conservative management is not the cutting-edge and preferred management nowadays. Although not fatal, it negatively impacts young people's quality of life in terms of schooling and means of subsistence and is socially awkward. Method About 10 individuals in this case series have serous drainage from the sinus in the sacral region, which is a common symptom. The patients were entitled to a full recovery from their illness. In all these patients, the Limberg flap procedure was recommended, and just one patient out of 10 had a minimal infection. Every patient was satisfied with how the surgery turned out. Overall, the Limberg flap (rhomboid flap) approach is becoming the norm for care since it has a lower rate of recurrence, fewer postoperative problems, and a shorter learning curve. Result Flap necrosis instances were absent in all the cases. And out of 10 cases, one patient came with a surgical site infection during the follow-up, suggesting a complication rate of 10%. Conclusion For the treatment of primary pilonidal illness, rhomboid excision utilising the Limberg transpositional fasciocutaneous flap technique is seen as a safer option that encompasses numerous sinuses. It requires less time in the hospital and has fewer postoperative problems.

Effect of estrus behavior on the paint removal score of the sacral region of nulliparous Bos indicus

O objetivo deste estudo foi correlacionar o comportamento do estro com o escore de remoção de tinta da região sacral (ERT) e avaliar a associação do ERT com o número de montas e comportamentos secundários do estro em fêmeas nulíparas de Bos indicus. Vinte e quatro protocolos de inseminação artificial em tempo fixo (IATF) de três manejos foram implementados para investigação do objetivo do estudo. A comparação entre ERT 3 e ERT 2 revelou diferenças significativas nas variáveis ​monta recebidas, execução de monta, descanso de queixo, cheirar ou ser cheirada, lamber e ser lambida, favorecendo o grupo ERT 3 (P &lt; 0,05), indicando estro. Entretanto, a comparação entre ERT 2 e ERT 1 não resultou em diferenças significativas nas características citadas, exceto no ser cheirada (P &lt; 0,05), indicando ausência de estro para esses dois escores. O número de montas recebidas em ERT 2 e 1 foi insuficiente para apagar as marcações. Conclui-se que o ERT se mostrou um indicador eficiente da manifestação do estro. Os comportamentos de estro das vacas nulíparas na ERT 3 foram mais evidentes que os da ERT 1 e 2, e os comportamentos manifestados na ERT 1 foram semelhantes aos da ERT 2, indicando ausência de comportamento de estro. Assim, sugere-se que no futuro o ERT seja apenas dividido em duas classes.

Caudal Regression Syndrome: A Case Report

Caudal regression syndrome is a rare malformation syndrome that involves varying degrees of agenesis of the sacral and coccygeal vertebrae, along with shortening of the lower limbs, and gastrointestinal, genitourinary, and cardiovascular anomalies. Its precise cause remains unknown, although its association with maternal diabetes is well established. We present a rare case of this syndrome in a one-month-old newborn whose mother has known diabetes and who also presents with anorectal malformation syndrome.

Treatment Outcomes of Lower Urinary Tract Symptoms due to Fragility Sacral Fractures: A Review of Eight Patients and Literature

Sacral fractures can cause lower urinary tract symptoms (LUTS) due to damage to the cauda equina. While several studies have reported on sacral fractures due to high-energy trauma, those due to fragility fractures have only been reported in case reports and their clinical differences are not well known. This study aimed to investigate the clinical characteristics of LUTS caused by fragility sacral fractures and propose a novel treatment strategy. This study is retrospective, uncontrolled, clinical case series. The inclusion criteria were sole sacral fractures due to low-energy trauma and appearance of LUTS after injury. Patients with additional spinal fractures or combined abdominal or pelvic organ injuries that could cause LUTS were excluded. Improvement in LUTS, period from onset to improvement, and imaging findings were recorded. Eight patients met the inclusion criteria (4 surgical and 4 conservative treatment cases). Six patients showed improvement in LUTS. In surgical cases, the mean period from onset of LUTS to surgery and from onset of LUTS to improvement was 14.5 and 21.5days, respectively. Intraoperative rupture or laceration of the dural sac was not observed. In 2 conservatively improved cases, the period from onset to improvement of LUTS was 14 and 17days. LUTS can improve even with conservative treatment and should be utilized as the primary choice. LUTS caused by severe sacral canal deformity and stenosis can be reversible, and the decision to perform surgical treatment is still timely if LUTS do not improve with conservative treatment for several weeks.