Paravertebral Tissue Research Articles

Aspergillus terreus spondylodiscitis following an abdominal stab wound: a case report

BackgroundAspergillus terreus, a saprophytic fungus, is recognized as an emerging pathogen in various infections in humans. However, bone and joint involvement is uncommon. To the best of our knowledge, only seven cases of spondylodiscitis caused by Aspergillus terreus have been reported previously in humans. We report a case of a patient with Aspergillus terreus spondylodiscitis following an abdominal stab wound.Case presentationA 74-year-old Japanese man with no particular medical history fell from a ladder and sustained a left abdominal stab wound from an L-shaped metal peg. Computed tomography showed the trace of the L-shaped metal peg from the left abdomen to the left rib and left kidney. The scan also showed an anterolateral bone avulsion of the left side of the T12 vertebral body, as well as fractures of the L1 left transverse process and the left 10th–12th ribs. He was hospitalized and treated with conservative therapy for 6 weeks. He was readmitted to the hospital with complaints of sudden back pain, numbness of both legs, and inability to walk 13 weeks after the fall. Magnetic resonance imaging findings were typical of spondylodiscitis. Gadolinium-enhanced T1-weighted magnetic resonance imaging indicated increased signal intensity at T11–T12 vertebral bodies and severe cord compression and epidural abscess at T11–T12 associated with infiltration of soft paravertebral tissues. On the seventh day after admission, he underwent partial laminectomy at T11 and posterior fusion at T9 to L2. The result of his blood culture was negative, but Aspergillus terreus was isolated from the material of T11–T12 intervertebral disc and vertebral bodies. His Aspergillus antigen was positive in a blood examination. Histological examination showed chronic suppurative osteomyelitis. On the 35th day after admission, he underwent anterior fusion at T11 and T12 with a rib bone graft. For 5 months, voriconazole was administered, and he wore a rigid corset. Posterior partial laminectomy at T11 and anterior fusion at T11 and T12 resulted in a good clinical course. The patient’s neurological dysfunction was completely recovered, and his back pain disappeared. Two years after the operation, computed tomography was performed and showed bone fusion at T11 and T12. Magnetic resonance imaging revealed no evidence of increased signal intensity at T11–T12 vertebral bodies and severe cord compression and epidural abscess at T11–T12.ConclusionsTo our knowledge, this is the first report of spondylodiscitis caused by Aspergillus terreus after an abdominal penetrating injury. The histological finding of chronic suppurative osteomyelitis and the radiological findings strongly suggested direct inoculation of Aspergillus terreus.

PB2189 FREE LIGHT CHAINS IN MULTIPLE MYELOMA: IS IT TIME TO EXTEND THEIR APPLICATION?

Background:Free Light Chain (FLC) assay is used for multiple myeloma screening, prediction of risk progression and response assessment as indicated by IMWG guidelines, particularly to define stringent complete response (sCR). The assay is also recommended in cases of unmeasurable (non‐secretory, NS) or low values of M‐protein (oligo‐secretory, OS).Aims:Here we describe the value of FLC assay in predicting extramedullary relapse in four MM patients.MethodsDuring the course of therapy, FLC was monitored routinely on a monthly basis.Results:An OS MM IgG κ patient (first case) started in May 2017 4th line KRd therapy, due to new lytic lesions, with negative BM biopsy. During the course of therapy, sIFE remained negative, while sFLC continued to rise (May 2017–March 2018: sFLC κ 175 vs 340 mg/L, rFLC 4.2 vs 19.9). In March 2018 a right femur mass appeared and histology, confirmed EMD relapse. Patient underwent surgical removal and rFLC returned within normal range (1.3).Considering that it was the only site of disease, KRD regimen was restarted in June 2018 for four more cycles. Unfortunately, in November 2018 the knee mass reappeared, and, once again, sFLC was altered (FLC κ 124 mg/L, ratio 25), with negative sIFE. Biopsy of the mass confirmed EMD relapse, BM biopsy remained negative.A patient with IgG κ MM (second case) started in May 2017 2nd line KRd therapy for disease progression, confirmed by BM biopsy. A partial response was obtained quickly, but since March 2018 a progressive rise of rFLC was noticed (March–September 2018: rFLC 0.67 vs 1.67), and it anticipated of 5 months the increase of MP (August 2018). In June 2018 patient complained vague gastrointestinal symptoms and in September a CT scan revealed hepatic nodularities, confirmed by biopsy as hepatic EMD.A LC MM λ patient (third case) started in March 2017 KRd as 2nd line treatment for disease progression (MP 0.7 g/dL, sFLC λ 2000 mg/dL, rFLC 171), with positive BM biopsy. Patient obtained CR after the first cycle, but during the treatment in June 2018 sFLC started increasing and in July alteration of liver and bilirubin tests was noticed, without any clinical sign, always with negative sIFE. In October 2018 sIFE became positive and in November MP reappeared (0.37 g/dL) while both the sFLC (June–November 2018: sFLC λ 53 vs 207 mg/dL; rFLC 6 vs 68) and the liver tests continued to rise. A solid hepatic mass was revealed and biopsy confirmed an EMD relapse.A MM IgA λ patient (fourth case) diagnosed with biopsy of soft paravertebral tissues, was treated with 1st line VMP treatment in September 2018. During the treatment the patient complained sight loss and a CT scan showed the presence of a right ocular mass. The MP was reduced while sFLC increased (September–October 2018: MP 2.4 vs 0.2 g/dL; sFLC λ 158 vs 263 mg/dL; rFLC 5.7 vs 29.4). Biopsy confirmed an aggressive EMD relapse and the patient started 2nd line KRD treatment in October 2018. A complete remission was obtained with ocular mass regression, negative sIFE and improvement of FLC.Unfortunately, in January 2019 during the fourth cycle, a cutaneous lesion appeared on the right tibia, confirmed as EMD relapse. While both the sIFE and BM biopsy remained negative, a slight increase of sFLC was noticed, although always within range.Summary/Conclusion:In all four cases an increase of FLC always preceded the diagnosis of EMD relapse irrespective of MP measurement. We therefore recommend serial use of sFLC assay, particularly in heavily pretreated patients for early detection of aggressive and/or EMD relapse.

Classifications of Non-Specific Hematogenous Vertebral Osteomyelitis. Critical Review and Suggestions for Clinical Use

For a long time classification of V.Ya. Fischenko published in 1983 and being solely descriptive was the main classification of vertebral osteomyelitis in the countries of the former ussr. In recent years some versions of tactical classifications appeared in the literature which were dedicated to standardization of tactics and methods of treatment. However, those classifications did not reflect distribution according to affection type, destruction degree, biomechanical instability and presence of neurological deficit and did not embrace all scenarios of disease progress.Purpose of the study — to compare existing classifications and to offer an adapted Russian language version of tactical classification for hematogenous vertebral osteomyelitis.Materials and Methods. The study included 209 patients with non-specific vertebral osteomyelitis treated in the period from 2006 till 2017. All cases of vertebral osteomyelitis were distributed in accordance with known classifications. The authors conducted the analysis of treatment tactics used in the clinic and by the authors of given classifications. The authors revealed a group of patients which is not classified in known literature.Results. Full match of treatment tactics with standardized approaches suggested by authors of new classifications was 61,5% (n = 126), partial match (applied treatment tactics does not contradict to suggested) — 20,0% (n = 41), which overall was 81,5% (n = 167). The authors refer to patients who underwent ventral sanation or reconstructive procedures. The majority of patients had the septic form of disease. Four out of 209 patients were not classified while three patients features isolated injury of vertebral processes and one patient — injury of CI-CII.Conclusion. Modern suggested classifications of hematogenous vertebral osteomyelitis are applicable in clinical practice and allow to standardize treatment algorithms. Tactics is determined not only by degree of destruction, involvement of paravertebral tissues, biomechanical instability of affected spine segment and neurological deficit, but by a presence of systemic inflammation response syndrome (SIRS). Considering the above it would be useful to introduce some additional subtypes which would characterize septic process of disease and determine the indications for sanation and reconstructive ventral procedures, which can be supplemented by instrumental fixation after stabilization of the patient.

Percutaneous Ozone Treatment for Herniated Lumbar Discs: 1-Year Follow-up of a Multicenter Pilot Study of a Handheld Disposable Ozone-Generating Device

PurposeTo evaluate the safety and efficacy of oxygen-ozone treatment delivered via a novel, handheld ozone-generating device for improving pain and function in herniated disc patients. Materials and MethodsA total of 39 patients with contained herniated lumbar discs received oxygen-ozone treatment at 1 of 3 centers. Treatment consisted of injection of 2% ozone (10 mL): 3 mL delivered into the nucleus pulposus and 7 mL delivered into the adjacent paravertebral tissues. The first 8 patients received only ozone injections, whereas subsequent patients also received periganglionic methylprednisolone (40 mg) and 0.5% bupivacaine (1 mL) injections. Patients were evaluated at baseline and at 1 month, 6 months, and 12 months after treatment using the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for leg pain and for back pain. Analgesic medication use was also assessed at each timepoint. ResultsOverall, 91% (32/35) of the per-protocol patients (those who completed follow-up and did not have significant protocol deviations) showed detectable improvement in ODI at 1-month follow-up; this increased to 93% (26/28) of patients at 12-months follow-up. At 1 month after treatment, 60% (21/35) of patients showed significant improvement in ODI scores (P = .01); 54% (19/35) showed significant improvement in VAS scores for leg pain (P = .05); and 49% (17/35) showed significant improvement in VAS scores for back pain (P = .12). At 6 months after treatment, 67% (22/33) of patients showed significant improvement in ODI scores (P = .02); 64% (21/33) showed significant improvement in VAS scores for leg pain (P = .01); and 52% (17/33) showed significant improvement in VAS scores for back pain (P = .12). At 12 months after treatment, 68% (19/28) of patients showed significant improvement in ODI scores (P < .01); 64% (18/28) showed significant improvement in VAS scores for leg pain (P < .01); and 61% (17/28) showed significant improvement in VAS scores for back pain (P = .09). Leg pain typically subsided more quickly than back pain. Use of analgesic medications also significantly decreased at all follow-up timepoints compared to baseline (P < .01). There were no adverse events or device-related issues. ConclusionsAt 1, 6, and 12 months after treatment, patients experienced significant improvements in pain and function as well as significantly decreased use of analgesic medication. Taken together with the absence of adverse events at 1-year follow-up, these data suggest that oxygen-ozone treatment is a safe and effective therapy for contained herniated discs.

Double Assurance of Epidural Space Detection Using Fiberoptics-Based Needle Design and Autofluorescence Technologies for Epidural Blockade in Painless Labor.

Purpose: Technology of reflectance spectroscopy incorporated with auto-fluorescence spectroscopy were employed to increase the safety of epidural placement in regional anesthesia which is generally used for surgery, epidural anesthesia, post-operative pain control and painless childbirth. Method: Ex vivo study of auto-fluorescence spectroscopy was performed for the para-vertebral tissues contained fat, interspinous ligament, supraspinous ligament and ligamentumflavum by multimode microplate reader at wavelength 405 nm for the purpose of tissue differentiation. A specially designed optic-fiber-embedded needle was employed to incorporate with both reflectance and autofluorescence spectroscopies in order to probe the epidural space as double assurance demands. In vivo study was carried out in a Chinese native swine weighted about 30 kg under intubated general anesthesia with ventilation support. The reflective (405 nm) and autofluorescence signals (λ and λ*) were recorded at 5 different sites by an oscilloscope during the needle puncture procedure from skin to epidural space in the back of the swine. Results: Study of either autofluorescence spectroscopy for tissue samples or ex vivo needle puncture in porcine trunk tissues indicates that ligmentumflavum has at least 10-fold higher fluorescence intensity than the other tissues. In the in vivo study, ligamentumflavum shows a double-peak character for both reflectance and autofluorescence signals. The epidural space is located right after the drop from the double-peak. Both peaks of reflectance and fluorescence are coincident which ensures that the epidural space is correctly detected. Conclusions: The fiber-optical technologies of double-assurance demands for tissue discrimination during epidural needle puncture can not only provide an objective visual information in a real-time fashion but also it can help the operator to achieve much higher success rate in this anesthesia procedure.

Dynamic adaptation of vertebral endplate and trabecular bone following annular injury in a rat model of degenerative disc disease.

Degenerative disc disease (DDD) is associated with longitudinal remodeling of paravertebral tissues. Although chronic vertebral changes in advanced stages of DDD are well-studied, very little data exists on acute vertebral bone remodeling at the onset and progression of DDD. To longitudinally characterize bony remodeling in a rodent model of disc injury-induced DDD. In vivo animal study involving a rat annulus fibrosus injury model of DDD. Eight female Lewis rats were assigned to intervertebral disc (IVD) injury (Puncture) or sham surgery (Sham). All rats underwent anterior, transperitoneal approach to the lumbar spine, and Puncture rats underwent annulus fibrosus injury at the L3-L4 and L5-L6 IVDs (n = 8 per group). Live micro computed tomography imaging (10-μm voxel size) was performed 1 week before surgery and postoperatively at 2-week intervals up to a 12-week endpoint. Bone morphology and densitometry of the cranial vertebral body and bony endplate were analyzed and reported with respect to the preoperative baseline scan. Sagittal Safranin-O/Fast-Green and Toluidine Blue histology evaluated using the Rutges IVD score and a custom vertebral endplate score. Vertebral trabecular tissue mineral density (TMD), vertebral trabecular spacing, endplate TMD, and endplate apparent bone mineral density were all significantly greater in Puncture compared with Sham at 4 weeks and each subsequent timepoint. Puncture rats exhibited marginally lower endplate total volume. Anterior endplate osteophyte formation and central physeal ossification were observed in Puncture rats. Endpoint histological analysis demonstrated moderate evidence of IVD degeneration, indicating that vertebral bone adaptation occurs in the acute phases of DDD onset and progression. Annulus injury-induced DDD leads to acute and progressive changes to the morphology and densitometry of bone in the adjacent vertebral bodies and endplates.

Longitudinal Evaluation of the Histological Changes in a Rat Model of Paravertebral Muscle Injury.

Introduction Thus far, few reports have described the time series histological variations in injured paravertebral muscle tissues for long durations, considering the type of pain. The purpose of this study is to evaluate histological changes in injured paravertebral muscles and dominant nerves considering the type of pain. Methods We used 59 eight-week-old male Sprague-Dawley rats. A 115-g weight was dropped from a height of 1 m on the right paravertebral muscle. Fluoro-Gold (FG), a sensory nerve tracer, was injected into this muscle. Hematoxylin and eosin (HE) staining and nerve growth factor (NGF) immunostaining of the muscle were performed for histological evaluation. L2 dorsal root ganglia (DRG) on both sides were resected, and immunohistochemical staining was performed for calcitonin gene-related peptide (CGRP, a pain-related neuropeptide) and for activating transcription factor 3 (ATF3, a neuron injury marker). Each examination was performed at 3 days, 1-3 weeks, and 6 weeks after injury. Results HE staining of the paravertebral muscle indicated infiltration of inflammatory cells and the presence of granulation tissue in the injured part on the ipsilateral side at 3 days and 1 week after the injury. Fibroblasts and adipocytes were present at 2-3 weeks. At 6 weeks, the injured tissue was almost completely repaired. NGF was detected at 2-3 weeks post injury and appeared to colocalize with fibroblasts, but was not observed at 6 weeks post injury. The percentage of cells double-labeled with FG and CGRP in FG-positive cells of the primary muscle was significantly higher in the injured side at 3 days and 1-3 weeks post injury (P < 0.05). However, at 6 weeks, no significant difference was observed. No significant expression of ATF3 was observed. Conclusions These results suggest that sensitization of the dominant nerve in the DRG, in which NGF may play an important role, can protract pain in injured muscles.

Submandibular synovial sarcoma mimicking a vascular lesion: A rare case report

Synovial sarcoma is a soft-tissue sarcoma of periarticular surfaces in close association with tendon sheaths, bursae, and joint capsules. Synovial sarcoma represents 5.6%–10% of all soft-tissue sarcomas. Knox suggested the name synovial sarcoma in the year 1936. These tumors are usually not found in soft tissues of head and neck region, and majority of tumors believed to take origin from paravertebral connective tissue spaces and manifest as parapharyngeal and solitary retropharyngeal masses near the carotid bifurcation. We present a rare case of biphasic synovial sarcoma of the submandibular region in a young male patient.

Paraspinal muscle hypotrophy and chronic discogenic low back pain

Summary Study aim: Low back pain is accompanied by deconditioning of trunk muscles due to pain limiting patients’ physical activity, but so far it has not been explained whether the changes in the structure of muscles are the cause of disc disease or its result. The aim of the study was to analyze the prevalence of segmental paraspinal muscle hypotrophy in patients with chronic low back pain and sciatica. Material and methods: The study involved magnetic resonance imaging (MRI) of 40 patients: 20 women and 20 men aged from 30 to 47, mean 39.51 ± 3.73 years, with single level disc extrusion at L4-L5. The entire cross-sectional area of the par­aspinal muscles, the adipose tissue area in the paraspinal muscles and the extensor muscle tissue area at the level of L4-L5 were measured and compared with the healthy L3-L4 level. T2-weighted axial slices were used to facilitate distinguishing between the muscle and the fat tissue. Results: Fat tissue ingrowth and paravertebral muscle tissue hypotrophy at the disc extrusion level were highly statistically significant (p &lt; 0.001) compared to the healthy level. Conclusions: 1. Ingrowth of the adipose tissue into the muscle tissue occurs only at the level of disc extrusion. 2. It seems rea­sonable to introduce strengthening exercises after the resolution of pain in order to rebuild the muscles of the spine.

Minimally invasive dorsal decompression-stabilization surgery in patients with overweight and obesity

The study aim was to assess the efficacy of a new low-invasive rigid fixation technique and traditional open spinal fusion in surgical treatment of degenerative lumbar spine diseases in patients with overweight and obesity. The study included 73 patients (49 males and 24 females, aged 53 (42; 65) years) with a BMI of more than 25 kg/m2. Two study groups were allocated: group I (MIS-TLIF, n=32) included patients operated on using an original technique of spinal canal reconstruction, interbody spinal fusion, and combined transpedicular stabilization; group II (O-TLIF, n=41) included patients who underwent single-level rigid stabilization through the median approach. The mean follow-up period was 34 months in group I and 40 months in group II. Comparative analysis assessed clinical parameters, intraoperative indicators, postoperative period specificity, instrumental data, and complications. Compared to the O-TLIF group, the MIS-TLIF group was characterized by a shorter time of surgery, X-ray exposure, activation, and hospital stay as well as by a smaller amount of blood loss. A comparative analysis of the pain severity (visual analogue scale) and performance status (ODI) in the follow-up period revealed significantly better results in group I, which was associated with smaller intraoperative injury to soft tissues. The total rate of postoperative complications was 9% in group I and 17% in group II (p=0.01). In this case, the interbody bone block formed in the long-term postoperative period in 88% of group I patients and in 83% of group II patients (p=0.15). According to the instrumental data, there was statistically significant greater muscular atrophy in the group after O-TLIF (p<0.001). The original technique of minimally invasive rigid stabilization is safe and highly effective in surgical treatment of degenerative lumbar spine diseases in patients with overweight and obesity. MIS-TLIF has a number of significant advantages over O-TLIF in the dynamics of clinical parameters and a low number of perioperative complications, which is confirmed by smaller injury to paravertebral tissues and a better performance status in the long-term postoperative period.

Primary meningeal sarcoma (fibrosarcoma) of cervical spine in an 11 yr old boy: An extremely rare case report

Abstract Primary meningeal sarcoma is a rare tumor in pediatric age group. Here we were reporting an extremly rare case report of an 11 year old boy presented with quadriparesis and bladder involvement. MRI revealed a cervical dural based tumor with extension to cord parenchyma and neural foramina involving paravertebral tissue. The histopathology revealed mesenchymal tumor with malignant potential which on immunohistochemical (IHC) study found to be vimentin positive fibrosarcoma.

Effect of Pb exposure on the cells and matrix of the intervertebral disc of rats

Degenerative spine diseases are common throughout the world. There are many factors that lead to these diseases. One of these exogenous factors may be Pb exposure. Most of the fundamental investigations about the negative effects of the Pb exposure have investigated the impact of high doses of Pb, while Pb exposure in low concentrations has been insufficiently studied. The nutrition of the intervertebral disc is provided by the vessels that grow into the vertebral bodies and the paravertebral tissue. This suggests the possibility that Pb penetrates from the bone to the intervertebral disc together with nutrients. This article reports an experimental study which was performed in rats aged 1.5 months (n = 40). Rats in the experimental group received lead acetate solution (230 mg of Pb per1 literof distilled water) as drinking water and the animals in the control group received distilled water for 10 weeks. In the isolated intervertebral discs, the content of Pb was determined by X-ray fluorescence spectrometry. The effect of lead on the structural organization of the intervertebral disc was investigated by light microscopy. The ultrastructural features of cells and the matrix intervertebral disc were studied by transmission electron microscopy. In the young animals after Pb exposure, a significant increase was found in the content of Pb in the intervertebral disc tissue, of 4.6 times compared to the control group. The histological analysis showed degenerative changes in the annulus fibrosus (AF) of the intervertebral disc. In the outer region cracks and defibration of the lamellae were observed. Large isogenic groups were detected in the inner region of the intervertebral disc. A decrease in the height by 12.2% in the outer parts and by 10% in the central part of the intervertebral disc was recorded. Also a reduction in the width of the lamellae by 8% was shown. Cell density of the annulus fibrous decreased by 12% and in the gelatinous nucleus pulposus (NP) by 24.2%. Electron microscopic analysis of the inner region of the AF of the intervertebral disc showed chondrocytes with electron-dense mitochondria, vacuolization of the cytoplasm, fragmented nuclei and destructive cavities. The matrix of the lamellae of the AF had a diverse electron density, so areas with high electron density of various sizes were observed. Collagen fibrils of the AF had blurred outlines, sometimes the transverse striation disappeared or it was irregular, which can indicate the matrix mineralization and possibly the accumulation of Pb in these areas. In the NP, the most notochordal cells revealed the formation of myelin figures. The effect of Pb at low concentration results in its accumulation in the tissues of the intervertebral disc of rats and causes degenerative changes in the intervertebral disc structure, leading to the reduction in the height of the intervertebral disc, decrease in the width of the lamellae and in cell density, thereby violating both the structures of matrix and cells. Future investigations of the collagen content of intervertebral disc after Pb exposure are needed.

Which is better Stainless Steel or Titanium alloy?

To investigate immunologic reactions after implantation of stainless steel (SS) alloy and titanium (Ti) alloy in a rat model. Macrophage and cytokine responses have been reported after the in vivo and in vitro application of different biomaterials. Wistar albino rats after an exploration of the thoracolumbar paravertebral muscle tissue of the subjects, group I underwent a sham surgery, and groups II and III were implanted Ti alloy and SS alloy rods respectively. The CD4, CD8, CD25 (IL-2R) (lymphocyte and CD4 gate), CD4+CD8+ and CD4+CD25+Foxp3+ (Tregs), IL-4, IL-10, IL-6, IL-17A, TGF-β, TNF-α in the blood were analyzed. CD4, CD25 (IL-2R), CD4+CD8+ and Tregs levels were lower in the Group III compared to the sham and Group IIs. IL-6, IL-17A, TGF-β and TNF-α levels in the G III showed a significant increase on all days in comparison with the sham and Group II. IL-4 and IL-10 levels, were lower in the Group III than those in the Group II; and a significant decrease was observed in the IL-10 level. While there was a reduction in IL-6 and IL-17A levels in the Group II as opposed to the sham group. As opposed to SS alloy, Ti alloy suppresses the development of inflammations by inhibiting proinflammatory response; strengthens the humoral immune system by intensifying the antibody-dependent immune response; triggers the development of immune tolerance by regulating the immune response; and activates the mechanism that prevents immune response-related damage from occurring.

Raman Spectroscopy Differentiates Each Tissue from the Skin to the Spinal Cord: A Novel Method for Epidural Needle Placement?

Neuraxial anesthesia and epidural steroid injection techniques require precise anatomical targeting to ensure successful and safe analgesia. Previous studies suggest that only some of the tissues encountered during these procedures can be identified by spectroscopic methods, and no previous study has investigated the use of Raman, diffuse reflectance, and fluorescence spectroscopies. The authors hypothesized that real-time needle-tip spectroscopy may aid epidural needle placement and tested the ability of spectroscopy to distinguish each of the tissues in the path of neuraxial needles. For comparison of detection methods, the spectra of individual, dissected ex vivo paravertebral and neuraxial porcine tissues were collected using Raman spectroscopy (RS), diffuse reflectance spectroscopy, and fluorescence spectroscopy. Real-time spectral guidance was tested using a 2-mm inner-diameter fiber-optic probe-in-needle device. Raman spectra were collected during the needle's passage through intact paravertebral and neuraxial porcine tissue and analyzed afterward. The RS tissue signatures were verified as mapping to individual tissue layers using histochemical staining and widefield microscopy. RS revealed a unique spectrum for all ex vivo paravertebral and neuraxial tissue layers; diffuse reflectance spectroscopy and fluorescence spectroscopy were not distinct for all tissues. Moreover, when accounting for the expected order of tissues, real-time Raman spectra recorded during needle insertion also permitted identification of each paravertebral and neuraxial porcine tissue. This study demonstrates that RS can distinguish the tissues encountered during epidural needle insertion. This technology may prove useful during needle placement by providing evidence of its anatomical localization.

Chronic Painful Osteoporotic Vertebral Compression Fractures (OVCFs) of Thoracolumbar Spine: Percutaneous Vertebroplasty versus Conservative Management among Egyptian Patients

Introduction Vertebral augmentation procedures are widely used today in treating Osteoporotic vertebral compression fractures (OVCFs) especially in acute and subacute fractures. However, percutaneous vertebroplasty for patients with chronic painful OVCFs has been less well studied. The purpose of this study is to compare the efficacy and safety of percutaneous vertebroplasty with conservative management for the treatment of chronic painful OVCFs in the thoracolumbar spine among Egyptian patients. Patients and Methods This prospective cohort study included 60 patients with chronic OVCFs (38 females, 22 males, mean age: 65.42 ± 8.63) who presented with severe back pain to the outpatient clinic during the period from October 2005 to December 2011. Twenty-eight patients were treated with percutaneous vertebroplasty (vertebroplasty group). Thirty two patients refused surgical treatment and constituted the control group (Conservative group). The inclusion criteria included: Chronic painful OVCFs (at least 3 months), at least 50 years old, T5 to L5, osteoporosis (T-score -2.5 or lower), Visual Analogue Scale (VAS) at least 5, and absence of neurological deficits. At presentation, all patients of both groups received back brace, analgesics, anti-osteoporosis therapy. All patients were evaluated with X-rays and CT scan, where Cobb angle and the anteroposterior height comparison (APHC) were measured. Overall pain and quality of life were assessed with the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). Results All patients were followed for at least 12 months (range, 12 to 28). Statistical analysis of the demographic data of the two groups could not reveal any significant differences. At latest follow up, there was significant improvement in Cobb angle and APHC in vertebroplasty group compared with conservative group ( p &lt; 0.05). Twenty nine patients (90.63%) showed complete union in the conservative group while all patients (100%) showed complete union in the vertebroplasty group at latest follow up. VAS and ODI were significantly better in vertebroplasty group than conservative group ( p &lt; 0.05) at latest follow up. Cement extravasation into the disc occurred in 2 patients (5.41%), and into the paravertebral tissue in 3 (8.11%); none was associated with neurological symptoms, cement embolism, or infection. Recent fracture occurred adjacent to the formerly cemented ones in 2 patients (7.14%) and in non-adjacent level in one (3.57%). In conservative group, 3 patients (9.37%) presented with new osteoporotic vertebral fractures in adjacent levels and 2 (6.25%) in non adjacent levels. Three patients (9.37%) showed non union. Conclusion Percutaneous vertebroplasty is safe and effective in treatment of symptomatic chronic osteoporotic vertebral compression fractures with significantly better clinical and radiological outcomes when compared with conservative management.

Epidural catheter fixation. A comparison of subcutaneous tunneling versus device fixation technique.

Background and Aims:The technique of securing the epidural catheter has a major bearing on the efficacy of epidural analgesia. Specific fixator devices, for e.g., Lockit epidural catheter clamp, which successfully prevents catheter migration, are available. The possibility of catheter snapping and surgical retrieval has been reported with tunneling of catheters. These techniques have not been compared for safety, efficacy and appropriateness of achieving secure epidural catheter fixation in the postoperative period.Material and Methods:A total of 200 patients who required postoperative epidural analgesia were included. They were randomized into two groups: Group I (n = 100) in whom epidural catheters were tunneled vertically in the paravertebral subcutaneous tissue and group II (n = 100) wherein a Lockit device was used to fix the catheter. Likert score was used to quantify patient's comfort during procedure. The techniques were compared for migration, catheter dislodgement, local trauma, catheter snapping and catheter obstruction.Results:12% of tunneled catheters had migrated significantly outward. 22% of patients had erythema and 77% had significant procedural discomfort in group I. In group II, 3% catheters had kinked and 14% had erythema from device adhesive.Conclusion:Our results support the use of Lockit device as a safe and comfortable fixation device compared to subcutaneous tunneling of catheters.

Treatment of Contained Herniated Lumbar Discs With Ozone and Corticosteroid: A Pilot Clinical Study

PurposeThe primary objective of this pilot study was to compare pain and function scores from patients before and after an ozone injection in combination with steroids and bupivacaine to treat herniated discs. A secondary objective was to correct some of the methodological weaknesses of some previously published ozone studies. MethodsFifty patients were enrolled; 1-3 mL of 2 wt% ozone in 98 wt% oxygen was delivered into the nucleus pulposus, and 7-9 mL into the adjacent paravertebral tissues. The oxygen/ozone treatment was followed by a periganglionic injection of corticosteroid and bupivacaine. All patients were evaluated 1 month after the treatment to quantify improvement in pain and function, and to monitor for potential adverse events. ResultsForty-four patients had intradiscal injections and were included in the analysis. After 1 treatment, 75.0% showed significant improvement in pain based on the visual analog scale (improvement >1.8), 72.7% showed significant improvement in function based on the Oswestry disability index (improvement >15%), and 79.5% showed improvement based on the modified MacNab criteria. There were no adverse events associated with the treatment. ConclusionsPatients showed significant improvement in pain and function after receiving ozone injections in combination with steroids and bupivacaine for the treatment of herniated discs. Because of the lack of a control group and short follow-up times, conclusions about the safety and efficacy of ozone injections for the treatment of herniated discs are not warranted. However, the results provide sufficient evidence that the risk and expense of an additional randomized controlled study is merited.

IgG4-related disease initially presented as an orbital mass lesion mimicking optic nerve sheath meningioma

We report a case of an optic nerve mass lesion associated with IgG4-related disease. A 39-year-old man presented with right blurred vision and proptosis 8years before admission. Magnetic resonance imaging showed a mass lesion in the center of the right orbit, which was diagnosed as optic nerve sheath meningioma by neuroradiologists and neurosurgeons. Irradiation was selected for treatment of the lesion on the basis of the radiological diagnosis; subsequently, the lesion gradually reduced in size. However, regrowth of an optic nerve mass lesion observed during the previous 2years caused remarkable exophthalmos, and removal of the orbital mass lesion was performed via a transcranial orbital approach. Pathological examinations resulted in a diagnosis of IgG4-related disease, and hematological tests revealed an elevated level of serum IgG4. Additional radiological examinations showed mass lesions in the left maxillary nerve, bilateral inferior alveolar nerves, paravertebral tissue, and left kidney. Treatment with oral steroids has produced a reduction in the size of these lesions.

Magnetic Resonance Imaging Features of Healing Status in Tuberculosis of Spine: A Prospective Independent Observer-Based Study

Introduction MRI plays an important role in the diagnosis of spinal tuberculosis with a high specificity and sensitivity. The role of MRI in predicting the healed status of caries spine to establish an end point of treatment is still not clear. In this study, we have proposed few MRI parameters of healed spinal tuberculosis and have attempted to formulate a scoring system to document healing. To find out the reliability of the proposed MRI parameters, we have statistically tested the scores given by three independent observers and assessed the interobserver reliability of the parameters. Material and Methods It is a prospective observational study. A total of 20 patients of spinal tuberculosis diagnosed clinico-radiologically and histopathologically after 1 year of ATD were enrolled. Patients younger than 20 years, with multifocal lesions, erratic tubercular treatment, and relapse and immunocompromised states were excluded. The pre and 1-year posttreatment MRIs were collected and a score sheet was used to assess healing. A total of 14 parameters (cord signal intensity, cord compression, epidural space involvement, vertebral body collapse, marrow signal change, posterior element, bony/ligamentous, paravertebral abscess, granulation, disc involvement, endplate changes, kyphosis, dislocation/subluxation, and coronal translation) and 6 MRI sequences (T1 axial and sagittal, T2 axial, sagittal, and coronal, and STIR sagittal) were used. Scoring was done by three independent observers (one radiologist, one neurosurgeon, and one orthopedic spine surgeon) who did not get any clinical detail of the patient. One-tailed t-test was used for statistical significance. A scoring system was proposed with the parameters which maximally predicted the healing status. Interobserver reliability was analyzed using intraclass correlation. Results Out of the 14 parameters considered, 4 showed the maximum pre- and posttreatment score difference (CI = 0.01) with excellent interobserver reliability (pre- and posttreatment intraclass correlation value of 0.94 and 0.78). Kyphosis, dislocation/subluxation, and coronal shift were not significant. These parameters were paravertebral abscess ( p = 1.43 × 10␂10), cord compression ( p = 2.53 × 10␂9), granulation tissue ( p = 2.84 × 10␂9), and epidural space (p = 0.0021) in descending order of significance. Each parameter was tested separately and best six sequences which had maximum mean difference in scores were chosen. These were paravertebral abscess (STIR sagittal), cord compression (T2 axial), paravertebral granulation (T1 sagittal and coronal T2), and epidural space involvement (T1 and T2 axial). Each option had a minimum score of 0 and a maximum score of 2 so that the total score ranges from 0 to 12. The mean posttreatment observer score was 6.3. Hence, we propose a scoring system in which healing could be labeled with maximum predictability if the score is below 2. Conclusion Paravertebral abscess (STIR sagittal), cord compression (T2 axial), paravertebral granulation (T1 sagittal/coronal T2), and epidural space involvement (T1 axial/T2 axial) are the best healing parameters with excellent interobserver reliability. A proposed score of &lt; 6 at 1-year follow-up is a fair predictor of healing. This being a pilot study needs to be tested in a larger cohort to validate the above data.

Functional Capacity, Adipose Tissue Compartments, Muscle Mass Quality, Coronary Calcium And Functional Capacity In Institutionalized Nonagenarians

Loss of muscle mass, but also decrease in muscle quality as a consequence of increased amount of intramyocellular adipose tissue (i.e., muscle fat infiltration) can adversely affect the ability of an older person to remain functionally independent PURPOSE: to compare the different adipose tissue (AT) compartments, muscle mass, muscle fat infiltration, functional capacity, coronary calcium, as well as associations among changes in different AT compartments between frail and robust nonagenarians. METHODS: Forty-two elderly subjects took part in this study: 29 institutionalized frail elderly (92.0±8 years) and 13 robust elderly (88.2±4.1 years). All patients underwent helical thoracic, abdominal and thigh computed tomography (CT) scanning. In addition, a non-enhanced prospectively ECG-triggered cardiac CT scan was performed to quantify the amount of coronary artery calcification and measure pericardial AT. Functional capacity was assessed through TUG and raise from a chair tests. RESULTS: The robust group presented significantly greater pericardial (153.1 ± 79.6 mm2 vs. 81.0 ± 35.5 mm2) and abdominal (249.4 ± 153.9 cm2 vs. 113.8 ± 112.1 cm2) AT area, as well as greater axial (42.9 ± 10.7 cm2 vs. 35.6 ± 9.2 cm2), appendicular muscle size (186.0 ± 48.1 cm2 vs. 139.6 ± 32.6 cm2) and high-density muscle tissue (greater muscle quality) (quadriceps: 72.4 ±13.0 vs. 56.8 ± 14.3 cm2) than the frail group (P<0.001). No differences between groups were observed in coronary calcium. As expected, robust group presented significant greater gait ability and raise from a chair ability than frail group. There were positive correlations between pericardial AT with visceral and subcutaneous AT values, as well as between pericardial AT and quadriceps, hamstrings, psoas and paravertebral low-density muscle tissues in the frail and robust groups (r=0.57 to 0.91, P<0.05). Raise from a chair ability was associated with muscle quality (r=0.59, P<0.05). CONCLUSIONS: Robust group presented greater muscle size and quality in the axial and appendicular muscles, as well as pericardial and abdominal AT area than the frail group. Frailty is associated with lower muscle size and high-density muscle tissue and functional capacity. Muscle-fat infiltration shares analogous pattern of visceral and pericardial AT distribution.