Extremity Numbness Research Articles

Ataxic variant of Guillain-Barre syndrome, with positive GD1b antibodies in an elderly male: a case report (P10-5.005)

<h3>Objective:</h3> Discuss an atypical presentation of ataxic GBS with positive GD1b antibody. <h3>Background:</h3> The clinical spectrum of Guillain-Barre syndrome (GBS) ranges from asymptomatic to rapidly progressive and fatal. Ataxic GBS is one of the rare presentations. It is characterized by profound ataxia without ophthalmoplegia. We report a case of atypical presentation of GBS with rapidly progressive neurological deficits in an elderly male. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 73-year-old right-handed male with past medical history of hypertension and hyperlipidemia presented with gait imbalance and distal extremity numbness for five days prior to presentation. He noted he was having difficulty walking but denied weakness. He reported “electricity” type pain in his arms and legs and perioral tingling. He denied any other neurological deficits. He denied recent illness or vaccination. Physical exam was remarkable for severe ataxia, areflexia, and mild nystagmus. An MRI of the brain, cervical and thoracic spine showed no pathology. Cerebrospinal fluid (CSF) sampling showed protein of 46 mg/dL and no cells with a negative CSF culture. An electromyogram showed motor-sensory non-length dependant non-axonal loss without demyelination. A diagnosis of variant Guillain-Barre syndrome was suspected, and the patient received a 5-day course of intravenous immunoglobulins (IVIG). Despite this the patient developed neuromuscular respiratory failure necessitating intubation. GD1b antibody titter was found to be elevated at 1:800 (reference &lt;1:100) <h3>Conclusions:</h3> The ataxic variant of GBS is a very uncommon disease pathology. This case highlights the importance of considering different subtypes and presentations of GBS and related disorders. Early diagnosis and treatment with IVIG are important for a good outcome. <b>Disclosure:</b> Dr. Valhuerdi Porto has nothing to disclose. Dr. Shnawa has nothing to disclose. Dr. Joseph has nothing to disclose. Dr. Scott has nothing to disclose.

Teaching NeuroImages: Cortical damage with leptomeningeal enhancement in neuromyelitis optica spectrum disorder

A 27-year-old woman presented with headache, weakness, and numbness in both lower extremities for 2 weeks. Two years ago, she had refractory hiccups and vomiting with associated area postrema lesions on MRI (figure, A–C). Workup for infectious disease was negative. Serum aquaporin-4–immunoglobulin G was positive. Recent MRI showed cortical damage adjacent to the cerebral falx with leptomeningeal enhancement (figure, D–F). Treatment with immunoglobulin and high-dose methylprednisolone produced a significant improvement of the symptoms and the follow-up MRI (figure, G–I). This patient's case is unusual, as neuromyelitis optica spectrum disorders rarely involve the cortex and pia mater.1,2

Nitrous Oxide-Induced Subacute Combined Degeneration in a 38-Year-Old Pregnant Female After Recreational Use

Nitrous oxide (N2O) misuse creates a diagnostic dilemma due to its clinical presentation, difficulty in identification, and toxicity related to its chronic abuse, with resultant morbidity and mortality. Chronic abuse can lead to myeloneuropathy and subacute combined degeneration in otherwise healthy individuals. Health professionals should be aware of the commercial availability and abuse of N2O by the public, and N2O toxicity should be included in the differential diagnosis in patients presenting with myelopathy of unknown etiology. A case report was conducted on a 38-year-old female at approximately 30 weeks of gestation who presented to the emergency department with worsening bilateral lower extremity numbness, tingling, and weakness. The patient admitted to nitrous oxide inhalation during the two months prior to admission. She reported using four cans of whippets per week (approximately 8 g of N2O per whippet) up to 50 cans per day (400 g N2O) prior to the onset of symptoms. An MRI of the cervical spine was performed, showing T2 hyperintensity from C2 to C6 involving dorsal columns indicative of subacute combined degeneration. The patient was treated with intravenous vitamin B12 due to the clinical and radiographic evidence of nitrous oxide-induced myelopathy. The pathophysiology of N2O toxicity involves the oxidation of the cobalt atom of cobalamin (vitamin B12) from its reduced active 1+ valent state to its oxidized inactive 3+ valent state. This oxidation inactivates the enzyme methionine synthetase. B12 is an essential cofactor for downstream DNA synthesis. Consequently, excess N2O creates functional B12 deficiency leading to irreversible nerve damage if left undiagnosed and untreated.

AYURVEDIC MANAGEMENT OF CERVICAL MYELOPATHY- A CASE REPORT

Introduction: Cervical Myelopathy is a neurological impairment caused by compression of the cervical spinal cord mostly due to degenerative cervical spondylosis. Axial imaging is the modality for diagnosis which shows myelomalacia and focal cord atrophy. Main clinical findings:A58 years old female with complaints of weakness of both legs since 6 months which aggravated past 2 months, associated with numbness of both soles and palms came to OPD of our hospital. Diagnosis: She was diagnosed and treated for cervical myelopathy. Depending on the clinical signs and symptoms of the patient the condition can be correlated to Khalli (Kaphavrutha vyana and raktavritavata). Intervention:The patient was managed with internal and external medications including ksharavasthi. Outcome: The treatment showed marked improvement in gait, pain, numbness in both extremities and urinary incontinence. Conclusion: This article is an attempt to shed light on the management of cervical myelopathy and to explore the scope of further study

Guillain-Barré syndrome in remission of Ulcerative colitis: a case report

This case report provides a unique instance of a patient who developed Guillain-Barré syndrome (GBS) during the remission phase of ulcerative colitis (UC). GBS is a rare but severe autoimmune disorder affecting the peripheral nervous system, while UC is a chronic inflammatory bowel disease. The co-occurrence of GBS and UC is rare, and its underlying mechanisms are not well understood. The patient's medical history and the course of their treatment are discussed in detail to provide a comprehensive understanding of the condition.The onset of GBS in this case report was characterized by lower extremity weakness and numbness of the upper extremities, which is consistent with the typical symptoms of GBS. The electromyography (EMG) results showed low limb nerve conduction and velocity with low amplitude, which supports the diagnosis of GBS. The treatment involved intravenous (IV) methylprednisolone, which is a commonly used steroid in the management of GBS. The patient showed improvement in his symptoms, with the weakness and numbness disappearing and muscle strength recovering, which is in line with the expected outcome of treatment with steroids.This case report provides valuable insight into the complex interplay between GBS and UC, and the potential impact of autoimmune diseases on each other. The findings of this report will contribute to the existing literature on GBS and UC, and help healthcare professionals to make informed decisions regarding the diagnosis and management of these complex conditions. The report concludes with a discussion of the implications of the case and the need for further research to better understand the relationship between GBS and UC.

Case Report-Traumatic L5-S1 Instability: Are Upright Radiographs Potentially Dangerous?

Traumatic lumbosacral instability is a rare but potentially devastating injury. These injuries are frequently associated with neurologic injury and often result in long-term disability. Despite their severity, radiographic findings can be subtle, and multiple reports exist in which these injuries were not recognized on initial imaging. Transverse process fractures, high-energy mechanisms, and other injury features have been suggested as indications for advanced imaging, which has a high degree of sensitivity in detecting unstable injuries. A 21-year-old man presented to our level I trauma center after being ejected in a rollover motor vehicle collision. He sustained multiple injuries, including multiple lumbar transverse process fractures and a unilateral superior articular facet fracture of S1. Initial supine computed tomography (CT) images showed no displacement of the fracture and no listhesis or instability. Subsequent upright imaging in a brace, however, demonstrated significant displacement of the fracture with dislocation of the contralateral L5-S1 facet joint and significant anterolisthesis. The patient underwent open posterior reduction and stabilization of L4-S1 followed by L5-S1 anterior lumbar interbody fusion. The patient demonstrated excellent alignment on postoperative imaging. At 3 months postoperatively, he had returned to work, was ambulating without assistance, and reported minimal back discomfort and no lower extremity pain, numbness, or weakness. This case serves as a warning that supine CT imaging alone may not be sufficient to rule out unstable lumbar spine injuries, such as traumatic L5-S1 instability, and that upright radiographs in these potentially unstable injuries may represent a hazard to patients. Fractures involving the pedicle, pars, or facet joints as well as multiple transverse process fractures and/or a high-energy mechanism of injury should all raise suspicion of instability and warrant additional imaging. This article provides guidance on approaching treatment for patients with potential traumatic lumbosacral instability.

Bilateral Hypoplasia of the Cervical Internal Carotid Arteries in a Pregnant Patient with Patent Foramen Ovale – A Case Report and Discussion

Introduction: Congenital hypoplasia or aplasia of the internal carotid artery (ICA) is believed to affect less than 0.01% of the population, with fewer than 200 unilateral and 30 bilateral cases reported in the literature. While often asymptomatic, they have been associated with stroke, transient ischemic attack (TIA), and other neurovascular pathologies. Case Report: We describe a 33-year-old 28 weeks pregnant female with a history of patent foramen ovale (PFO) and ischemic stroke in the right middle cerebral artery (MCA) distribution three years prior who experienced new onset transient right upper extremity weakness and numbness. Duplex sonography revealed bilateral hypoplasia of the internal carotid arteries (HICA), confirmed by CT and MR angiography of the head and neck. Discussion: To our knowledge, this is the first reported case of bilateral HICA with concurrent PFO and pregnancy presenting with TIA. All three conditions are associated with stroke and TIA. HICA should be included in the differential diagnosis of neurologic deficit despite its rarity.

Persistent Sciatic Artery in Right Lower Extremity Complicated by Thrombosis: A Case Report.

Persistent sciatic artery (PSA) is a rare congenital vascular malformation with an incidence of approximately 0.025% to 0.04%. Persistent sciatic artery has major complications, such as aneurysms, thrombosis, and occlusion. Complications may lead to a range of serious clinical problems, and a timely diagnosis of this vascular variant is crucial to avoid life-threatening complications. A 65-year-old man was admitted to the hospital with pain and chills in the right lower extremity for 2 months, which gradually worsened. This was accompanied by numbness in the right foot for the last 10 days. Computed tomography angiography showed that the right inferior gluteal artery and right popliteal artery of the right internal iliac artery were connected, which is considered a congenital developmental variant. This was complicated by multiple thromboses of the right internal and external iliac arteries, and the right femoral artery. After admission to the hospital, the patient underwent endovascular staging surgery to relieve numbness and pain in the lower extremities. Treatment strategies can be selected based on the anatomical characteristics of PSA and superficial femoral artery. Asymptomatic patients with PSA can be closely monitored. Surgery or individualized endovascular treatment plans should be considered for patients with aneurysm formation or vascular occlusion. For the rare vascular variation of the PSA, clinicians must make a timely and accurate diagnosis. Ultrasound screening is essential, which requires experienced ultrasound doctors to be aware of vascular interpretation and develop personalized treatment plans for each patient. In this case, we adopt staged a minimally invasive intervention to solve the problem of lower limb ischemic pain for patients. This operation has the advantages of rapid recovery and less trauma, which has important reference significance for other clinicians.

Association between phase angle and functional disability among patients with lumbar spinal stenosis: The SPSS-OK study.

Whether the lower phase angle associated with worse physical function is a result of pain and muscle weakness in patients with lumbar spinal stenosis (LSS) is unclear. To evaluate the association between phase angle and back pain-specific disabilities in patients with LSS. In this single-center, cross-sectional study, 491 participants with LSS were enrolled. The phase angle and back pain-specific disability were measured using bioelectrical impedance analysis and the Oswestry Disability Index, respectively. General linear models were used to examine associations between phase angle and the Oswestry Disability Index with or without adjustment for age, sex, low back and lower limb pain, numbness in the lower extremities, total fat mass, and lower limb muscle mass. The mean (SD) phase angle was 4.4∘ (1.0∘), and the mean Oswestry Disability Index was 36.1 (14.1) points. Greater phase angles were associated with less Oswestry Disability Index points (p= 0.037) independent of fat mass, low back pain, and hip or lower limb pain. A lower phase angle was associated with worse functional disability. Low phase angle may be an indicator of functional impairment due to low back pain associated with LSS.

Effect of Preoperative Severity and Location of Lumbar Intervertebral Disc Vacuum Phenomenon on Surgical Outcomes After Single-Level Transforaminal Lumbar Interbody Fusion

This study aimed to examine whether preoperative severity and location of lumbar intervertebral disc vacuum phenomenon (VP) influence surgical outcomes after single-level transforaminal lumbar interbody fusion (TLIF). We included 106 patients (age: 67.4 ± 10.4 years; 51 male/55 female) with lumbar degenerative diseases, who were treated with single-level TLIF. Severity of VP (SVP) score was measured preoperatively. SVP score at fused disc was used as SVP (FS) score, and at non-fused discs was used as SVP (non-FS) score. Surgical outcomes were assessed using Oswestry disability index (ODI) and visual analogue scale (VAS; low back pain (LBP), lower-extremity pain, numbness, LBP in motion, in standing, and in sitting). The patients were divided into Severe VP (FS or non-FS) and Mild VP (FS or non-FS) groups, and surgical outcomes were compared between the two groups. Correlations between each SVP score and surgical outcomes were analyzed. There were no differences in surgical outcomes between the Severe VP (FS) and Mild VP (FS) groups. Postoperative ODI, VAS for LBP, lower-extremity pain, numbness, and LBP in standing were significantly worse in the Severe VP (non-FS) group than in the Mild VP (non-FS) group. SVP (non-FS) scores significantly correlated with postoperative ODI, VAS for LBP, lower extremity pain, numbness, and LBP in standing; however, SVP (FS) scores did not correlate with any surgical outcomes. Preoperative severity of VP at fused disc is not associated with surgical outcomes, however, severity of VP at non-fused discs is correlated with clinical outcomes.

Efficacy of Alexander Technique Versus Progressive Relaxation Technique in Improving the Functional Activity of Security Guards with Mechanical Low Back Pain- A Randomized Experimental Trial

Low Back Pain is quite common in them. Changes in posture or poor body mechanics may cause the above spine-related problems, causing other muscles to be misused and become painful. However, mechanical Low Back Pain usually does not cause weakness or numbness in the lower extremities because the problem is not due to compression of the spinal nerves. The study aims to compare the effectiveness of the Alexander and progressive relaxation techniques in inducing relaxation and improving the functional activity of individuals with mechanical low back pain. It is a simple experimental study. For the study, 40 subjects were divided randomly into groups, namely group A and group B, each consisting of 20 subjects. Group A was given the Alexander technique, and Group B was given the progressive relaxation technique. The Visual Analogue Scale and the Oswestry Disability Index were used.: The collected data were recorded and tabulated. The data were analyzed using the Statistical Package for Social Science (SPSS 20 version – USA ) to present the study's findings. Comparison of pre-and post-visual analog scale (VAS) using the Alexander technique shows pre-VAS 6.75 and post-VAS reduced to 2.55, given t-value 20.03, thus providing significant results with p&lt; 0.001 s.s. Comparison of pre and post-VAS using progressive relaxation technique shows pre-VAS at 6.9 and post-VAS reduced to 3.6. Given a t-value of 14.91 gives a significant result with a p&lt; 0.001. This study concluded that the Alexander technique is more effective in mechanical low back pain subjects. This study will help select interventions in mechanical low back pain subjects.

A novel nonsense variant in the ATL3 gene is associated with disturbed pain sensitivity, numbness of distal limbs and muscle weakness.

Introduction Hereditary sensory neuropathy (HSN) describes as a heterogeneous group of peripheral neuropathies. HSN type 1 (HSN1) is one subtype characterized by distal sensory impairment that occurs in the form of numbness, tingling, or pain. To date, only two variants in the atlastin GTPase 3 (ATL3) gene have been identified that result in hereditary sensory neuropathy type 1F (HSN1F) with autosomal dominantinheritance. Methods We sudied and examined who present with sensory disturbances and muscle weakness in their lower limb. Patients underwent Whole Exome Sequencing and Sanger sequencing was performed in families for validation of detected variant. Results Here, we identified two Iranian families carrying the novel heterozygous stop variant NM_015459.5: c.16C>T, p.Arg6Ter in ATL3 that led to disturbed pain and touch sensitivity. This variant in the ATL3 gene was detected in both families (NM_015459.5: c.16C>T, p.Arg6Ter) by whole-exome sequencing and confirmed by Sanger sequencing. Conclusion In this study, the subjects manifested weakness of distal limb muscles and numbness of the lower extremities. In addition, some unusual features, including hearing problems and inability to sit and walk presented in one of the patients. Eventually, we provide a case-based review of the clinical features associated with HSN1F. Hitherto, only 11 patients with HSN1F have been reported. We compared our findings to previously reported cases, suggesting that the clinical features are generally variable in the HSN1F patients.

Abstract Number ‐ 225: COVID‐19 As A Potential Inducer Of Antiphospholipid Syndrome In A Patient With Acute Ischemic Stroke

Introduction COVID‐19 has been linked to hypercoagulability and acute ischemic stroke, though the precise mechanism is not well understood [1]. Various mechanisms have been suggested, including the potential release of autoantibodies‐ either via self‐production or exacerbation of the release of already produced autoantibodies [2‐3]. Antiphospholipid antibodies have been identified in severe disease [3‐4] and implicated in thrombosis [1‐2], though the significance is unclear. In this report, we describe a young woman with asymptomatic COVID‐19 presenting with acute ischemic stroke and postulate it was a manifestation of activated autoimmunity from COVID‐19. Methods Case Report Results A 22 year‐old previously healthy woman presented with acute onset dysarthria and right upper extremity weakness and numbness. On presentation, blood pressure was 158/101. NIHSS was 2 for right upper extremity drift and decreased sensation. Neurologic exam was otherwise unremarkable. Thrombolytic therapy was not administered given presentation outside the time window. CT head showed scattered left centrum semiovale hypodensities without hemorrhage. MRI brain demonstrated multifocal areas of diffusion restriction in the left centrum semiovale, anterior frontal lobe, and parietal lobe. CT angiogram demonstrated a possible thrombus at the left carotid bifurcation which was redemonstrated on MR angiography of the neck. No atherosclerotic plaque, hemodynamically significant stenosis, nor other vascular abnormality were appreciated. Heparin drip was started. Hemoglobin was 6.9 for which 1 unit of packed red blood cells was transfused. White blood cell count was 9.02. Platelet count was 761. PT/INR and PTT were 13.4/1.2 and 30.1. HIV was negative, RPR was positive at 1:128 titer, and COVID PCR was positive. She did not experience respiratory symptoms. Urine drug screen was positive for cannabinoids. LDL was 66. Transthoracic echo demonstrated minimal right to left shunting, suggesting patent foramen ovale. Ejection fraction was 60–65% and chamber sizes were normal. Bilateral lower extremity ultrasound was negative for deep vein thrombosis as a potential embolic source given cardiac shunt. Given history of miscarriage and extensive family history of sickle cell trait, possible lupus anticoagulant, and thrombosis at young ages, hypercoagulable workup was sent. Sickle cell preparation and ANA were negative. ESR was 12. High sensitivity CRP was 2.71. Anticardiolipin IgM antibody was elevated significantly at 125.9 MPL and IgG antibody was indeterminately elevated at 19.2 GPL. Beta‐2 glycoprotein IgM antibodies were also elevated at 42 SMUnits. Atypical neurosyphilis was considered given positive titer, middle cerebral artery distribution, and young age, but deemed unlikely given embolic rather than inflammatory stroke pattern [5]. Ultimately, with a possible diagnosis of antiphospholipid syndrome, anticoagulation was transitioned to warfarin via enoxaparin bridge with plan for repeat hypercoagulable workup as outpatient. Conclusions COVID‐19 has been observed in association with hypercoagulable states such as deep venous thrombosis and stroke. Here we present a case of COVID‐19 associated ischemic stroke with concomitant antiphospholipid antibodies. This case highlights the potential for even asymptomatic/mild COVID‐19 to induce autoimmunity through modulation of host antibody activity. This may be more profound in those with a predisposition to thrombosis. Autoimmunity should be considered in cases of concurrent COVID‐19 and acute ischemic stroke without clear etiology.

Carotid body paraganglioma metastatic to spine causing cord compression: a case report

BackgroundCarotid body tumors (CBTs) are rare neuroendocrine neoplasms arising near the carotid bifurcation with a reported incidence of 1 to 2 cases in 100,000 patients. Most CBTs are sporadic, benign, slow-growing, and non-secreting, but untreated CBTs can grow locally to compress the nearby blood vessels, esophagus, and airway. Regional metastases can occur in 5% to 10% of cases, but distant metastases are exceedingly rare, occurring in roughly 1–2% of cases. As such, the optimal treatment for metastatic CBTs is not well-defined. We report a rare case of a patient with CBT distant metastases causing spinal cord compression.Case presentationA 40-year-old African American female presented with a right neck mass, headaches, vertigo, tinnitus, hoarseness, and dysphagia. Imaging demonstrated a Shamblin II right neck mass; subsequent transcervical resection and pathology showed a carotid body paraganglioma. The patient recurred locally near the carotid bifurcation, so she underwent Stereotactic Body Radiation Therapy to the recurrent right neck disease. She later re-presented with new onset bilateral lower extremity weakness, dysmetria, and numbness. She was found to have metastatic disease to the thoracic spine causing spinal cord compression. She underwent laminectomy, tumor resection, and posterior fixation followed by adjuvant radiation therapy. She was started on systemic therapy with sunitinib. She eventually progressed with metastatic disease to the right iliac bone, which was treated with palliative radiotherapy. Second line systemic therapy with capecitabine and temozolomide was started. At last follow up, the patient was asymptomatic with stable persistent disease.ConclusionsParagangliomas often exhibit a prolonged interval to the development of progression; locoregional recurrences or rare distant metastases have been reported to occur as many as 20 years from diagnosis. The natural course of CBTs in other cases as well as the present case call into question the idea that CBTs are truly benign; instead CBTs may be indolent tumors with metastatic potential. Treatment choices for CBTs include surgical resection, radiation therapy, and systemic therapy, though the optimal treatment regimen for metastatic CBTs is not well-defined. A more advanced understanding of CBT pathophysiology, disease classification, risk stratification, and treatment options is needed to improve outcomes for patients.

Are paraspinal muscle quantity, lumbar indentation value, and subcutaneous fat thickness related to disc degeneration? An MRI-based study

IntroductionThe aim of the study was to investigate the relationship between lumbar disc herniation and Goutallier classification (GC), lumbar indentation value, and subcutaneous adipose tissue thickness. Methods102 consecutive patients (59 female and 43 male) with lumbar back pain, numbness, tingling, or pain in the lower extremity indicating radiculopathy who had undergone lumbar magnetic resonance imaging (MRI) and had an intervertebral disc herniation in the L4-5 level, were included in the study. 102 patients who have undergone lumbar MRI in the same time period and have no disc herniation were chosen to be the control group and were selected so as to match the herniated group for sex and age. All these patients’ scans were re-interpreted regarding paraspinal muscle atrophy (using the GC), lumbar indentation value, and subcutaneous adipose tissue thickness in the L4-5 level. ResultsThe Goutallier score was higher in the herniated group, compared with the non-herniated group (p < 0.001). There was no statistical difference between herniated and non-herniated groups regarding lumbar indentation value (LIV) and subcutaneous adipose tissue thickness (SATT). A Goutallier score of 1.5 provided the highest sensitivity x specificity value to indicate the disc herniation according to the statistical results. The individuals with a Goutallier score of 2, 3, and 4 have 2.87 times more likely to have disc herniation in their MRIs than the ones with a score of 0 and 1. ConclusionParaspinal muscle atrophy seems to be related to the presence of disc herniations. The cut-off value of GC to indicate the disc herniation in this study might be useful to predict the risk for disc herniation regarding the Goutallier score. The LIV and SATT measured in magnetic resonance images were randomly distributed between individuals with herniated and non-herniated groups, and statistically, no relationship was observed between these groups regarding these parameters. Implications for practiceThe effect of the parameters studied in this research on disc herniations are expected to be an added value to the literature. The awareness of risk factors for intervertebral disc herniations might be used in preventive medicine to predict the risk and understand the tendency of an individual for disc herniations to occur in the future. Further investigations are needed to establish whether there is a causal relationship or correlation between these parameters and disc herniation.

Transverse myelitis following bivalent COVID‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Transverse myelitis following bivalent <scp>COVID</scp>‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?

BackgroundVitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. Case ReportA 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. Why Should an Emergency Physician Be Aware of This?Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.

Comparative Clinical Analysis of Oblique Lateral Interbody Fusion at L5/S1 versus Minimally Invasive Transforaminal Interbody Fusion (MIS-TLIF) for Degenerative Lumbosacral Disorders.

Since 2015, we have performed minimally invasive oblique lateral interbody fusion (OLIF) at L5/S1 for various lumbosacral spine disorders using percutaneous pedicle screws. This study evaluated the clinical and radiologic results between OLIF at L5/S1 and minimally invasive transforaminal interbody fusion (MIS-TLIF) for single to multilevel degenerative lumbosacral disorders. A total of 124 patients underwent either OLIF (62 cases) or MIS-TLIF (62 cases). The applied disorders were L5 isthmic spondylolisthesis, foraminal stenosis, pseudarthrosis, adjacent segment degeneration, a combination of L4/5 and L5/S1 pathology, and others. We performed OLIF with posterior percutaneous fixation in the same lateral position. MIS-TLIF was performed with modified cortical bone trajectory screws. The operation time (OT), estimated blood loss (EBL), JOABPEQ effectiveness rate (%),Visual Analog Scale (VAS), fusion rate, radiologic segmental alignment, and complications were evaluated. The average follow-up periods were 51 and 69 months (24-95) in the OLIF and MIS-TLIF groups, respectively. Furthermore, the average fused segments were 1.6 and 1.5 in each group, respectively. The OT and EBL per segment were 130 min and 56 mL and 100 min and 64 mL, respectively. The JOABPEQ effectiveness rate in the OLIF group demonstrated a statistically higher value in the domains of pain, low-back function, and gait than the MIS-TLIF group (P<0.01). The follow-up VAS of low-back pain (LBP) and lower extremity numbness had lower values in the OLIF group (P<0.05). The fusion rates were 98% and 90%, respectively. Segmental lordosis at L5/S1 was significantly larger in the OLIF group (15° vs. 11°, P<0.01). The OLIF group demonstrated less pain as well as better low-back and gait functions at follow-up. The minimally invasive anterolateral fusion employing OLIF at L5/S1 using percutaneous screws serves as a viable and effective procedure with less residual LBP and high fusion rate.

Acute transverse myelitis associated with Covishield Vaccine: A case report

The patient included in this case study, Kavita Muthe, is from the Ahmednagar district’s Shrirampur hamlet. She is 36 years old, weighs 70 kg, is 162 cm tall, works as a homemaker, and has two children. After receiving the Covishield immunization two years prior, she had low back pain and lower extremity numbness. She visited the village doctor, who gave her some temporary medication.

Concomitant Thoracic Spinal Dural Arteriovenous Fistula and Spinal Cavernous Malformation

Both spinal dural arteriovenous fistula (SDAVF) and spinal cavernous malformation (SCM) are uncommon vascular malformations. To our knowledge, such a case of SDAVF concomitant with SCM has not been reported. We encountered a case of a 55-year-old man who had weakness and numbness in both lower extremities. Magnetic resonance imaging showed a round-shape lesion identified as a cavernous malformation in the middle segment of the thoracic spine, with spinal edema and obvious flow voids. Diagnostic angiography revealed an SDAVF fed by the right T7 radicular artery with venous drainage. The intramedullary venous hypertension due to fistula was suspected of inducing the formation of SCM. This case may provide new insight into the pathogenesis of SCM.