Sacral Spine Research Articles

Metastatic Malignant Paraganglioma: A Case Report

Abstract Objectives Paragangliomas are rare neuroendocrine tumors that arise from chromaffin cells with the ability to secrete catecholamines. The estimated combined prevalence is between 1:6,500 and 1:2,500. Paragangliomas can have a benign or a malignant course with incidence of malignant paraganglioma estimated to be 93/400 million. The majority of paragangliomas are sporadic but may be related to syndromes like multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and neurofibromatosis type 1. Methods We present a unique case of a 25-year-old female who presented with a hepatic mass. Further workup showed an enhancing hypervascular mass along with lesions within the bilateral lungs, liver, spleen, and sclerotic osseous metastatic disease at cervical thoracic lumbar and sacral spine. A liver biopsy was performed, which was consistent with the diagnosis of a metastatic paraganglioma. Results The liver biopsy showed a tumor consisting of epithelioid and polygonal tumor cells with eosinophilic cytoplasm present in a vascularized fibrous stroma in a sinusoidal pattern. In certain areas, the tumor cells show marked pleomorphism with large cells with macronuclei and bizarre shapes. On immunohistochemistry (IHC), the tumor cells were strongly and diffusely positive for CD56 and vimentin and focally positive for synaptophysin and chromogranin. S100 highlighted sustentacular cells. Ki-67 was very low, staining less than 2%. In addition, the tumor cells showed loss of expression of SDHB by IHC. Conclusion Metastatic malignant nonsecretory paraganglioma is an extremely rare disease. The most unique pathological aspect of paragangliomas is that tissue acquired from different organ appears the same histologically and yet different in terms of prognosis. Metastatic hepatic paraganglioma in our patient offers interesting insights to appreciate the rare metastatic nature of paraganglioma to the liver. The elusive nature of the metastatic disease in paraganglioma poses a challenge to clinicians since the diagnosis of metastatic hepatic paraganglioma is usually clinically undiagnosed.

Clearance of cerebrospinal fluid from the sacral spine through lymphatic vessels.

The pathways of circulation and clearance of cerebrospinal fluid (CSF) in the spine have yet to be elucidated. We have recently shown with dynamic in vivo imaging that routes of outflow of CSF in mice occur along cranial nerves to extracranial lymphatic vessels. Here, we use near-infrared and magnetic resonance imaging to demonstrate the flow of CSF tracers within the spinal column and reveal the major spinal pathways for outflow to lymphatic vessels in mice. We found that after intraventricular injection, a spread of CSF tracers occurs within both the central canal and the spinal subarachnoid space toward the caudal end of the spine. Outflow of CSF tracers from the spinal subarachnoid space occurred predominantly from intravertebral regions of the sacral spine to lymphatic vessels, leading to sacral and iliac LNs. Clearance of CSF from the spine to lymphatic vessels may have significance for many conditions, including multiple sclerosis and spinal cord injury.

Лучевая терапия остеохондродисплазии у шотландских вислоухих кошек

Osteochondrodysplasia in the Scottish Fold cats is the genetic disease, inherited according to the autosomal-dominant type; it is manifested by the deformation of bones and cartilages of the skeleton in the form of unhealthy bone growths in the region of the wrist, metacarpal, fetlock, mesopodial and phalanx joints of breast and pelvic extremities, and also tailed vertebrae.
 
 Purpose of research. To assess the effectiveness of radiation therapy in the treatment of Scottish fold cats with osteochondrodysplasia.
 
 Materials and methods. 10 Scottish Fold cats (3 males, 7 females; age ― from 5 months to 10 years) with osteochondrodysplasia were treated from 2013 to 2017. All patients had clinical signs of disease in the form of skeletal growths in the wrist, metacarpus, finger bones, lumbar, sacral or tail spine. Most of them (9 of 10) were lame. All patients were examined clinically and radiologically before the treatment. Radiation therapy was carried out on gamma therapy unit «AGAT-R» with inclusion of the affected limbs to the middle of the shoulder or thigh. Immobilization was achieved either by general anesthesia or by means of physical restraint. Fraction doses used were 1.5 Gy up to total doses of 15.0 Gy, 2 to 3 fractions per week.
 
 Results. In 9 of 10 cases (90 %) there is a subjective improvement in mobility and regression of lameness after 6 months and furthermore after treatment. Two patients in the group died within 8 and 12 months from extraneous causes, others are alive and well for the time being with no need for pain relief. In three cases a radiological control of skeletal growths was performed, with no signs of progression 6.15 and 71 months after treatment. The maximum observation period is 2196 days, the observation median is 705 days.
 
 We used a questionnaire to improve the objectiveness of cat’s mobility and pain assessment before and after treatment. Based on animal owners’ answers the score for each symptom was assigned from 0 (severe dysfunction) to 2 (function not impaired). Scores from individual cases were summed, and the averaged total results were compared. Generally, after radiation therapy, animals’ mobility improved significantly (the averaged mobility score in the group imcreased from 3.0 to 6.5).
 
 Conclusion. The radiation therapy is an effective pathogenetic and symptomatic method of treatment of Scottish fold cats with osteochondrodysplasia: in most cases it leads to pain relief and increased mobility of the animal. According to clinical and radiological (in three cases) criteria, it can also be assumed that radiation therapy leads to suppression of the skeletal growths enlargement. The effect of treatment develops within 6 months after its completion and is persistent (lasts for many months and years). The technique involves the use of small total doses, so it does not cause complications and is practically safe for the patient.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Classifications in Brief: The Spinal Instability Neoplastic Score.

The Therapeutic Benefit of Radiotherapy for Chordoma Patients with Positive Surgical Margins

Background: The role of radiation therapy (RT) for the treatment of chordomas remains incompletely described. Previous studies have not found adjuvant RT to improve overall survival (OS), but these studies did not group patients based on surgical margin status or radiation dose or modality. We used the National Cancer Database to investigate the role of RT in chordomas. Methods: Patients were stratified based on surgical margin status (positive vs negative). Utilizing the Kaplan Meier method, OS was compared between treatment modalities (surgical resection alone, therapeutic RT alone, and surgical resection plus therapeutic adjuvant RT). OS was also compared between patients treated with palliative dose ( 65Gy) RT. Similarly, OS was compared between advanced RT modalities including proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), and external beam radiation therapy (EBRT). A multivariable model was used to determine adjusted variables predictive of mortality. Findings: 1,478 chordoma patients were identified; skull base (n=567), sacral (n=551), and mobile spine (n=360). The 5-year survival for the entire cohort was 76%. Surgical resection and therapeutic adjuvant RT improved 5-year survival in patients with positive surgical margins (82% vs 71%, p=0·03). No clear survival benefit was observed with the addition of adjuvant RT in patients with negative surgical margins. High dose RT was associated with improved OS compared to palliative and low dose RT (p 65Gy) was superior to palliative/low dose EBRT (< 65Gy) (HR 0.52:95%CI 0.33-0.84, p=0·007). Interpretation: Patients with positive surgical margins benefit from adjuvant RT. Optimal OS is associated with adjuvant RT administered with advanced techniques and a cumulative dose >65 Gy. Funding Statement: No funding was obtained for this study. Declaration of Interests: None of the authors have any conflicts of interests pertaining to this study. Ethics Approval Statement: This study received appropriate IRB approval prior to collecting patient data.

Primary Spinal Nonsacral Ewing’s Sarcoma with an Unusual Presentation-a Case Report

Primary malignant sarcomas of the spine are not among common types of primary bone sarcomas. There are only few cases reported on the literature about this tumor. Ewing sarcoma occurring in the spine is divided into two types: 1) sacral spine Ewing sarcoma, which is very aggressive with poor prognosis and 2) non-sacral spine Ewing sarcoma, which is an extremely rare occurrence. The patient may present neurological deficit when the tumor extends into the spinal canal causing spinal cord compression; however, a sudden progressive paraplegia also is very rare. Here, we report a case of 8 years girl with sudden weakness and tingling in both lower limbs, inability to walk, progressive neck and upper dorsal pain, and urinary retention problem. Spinal MRI shows extradural mass from T2 to C7 with severe spinal cord compression. Urgent decompressive laminectomy and GTR of the lesion was done with excellent postoperative outcome

Hydrocephalus associated with multiple Tarlov cysts

Tarlov cysts (TCs) consist of dilated nerve root sheaths filled with cerebrospinal fluid (CSF) and are most frequently found in the sacrum. It is estimated that 25% of detected TCs cause chronic pain and intestinal and urogenital symptoms due to compression of the sacral nerve root fibers inside the TC. Unfortunately, symptomatic TCs are frequently overlooked.It is assumed that TCs result from pathologically increased hydrostatic pressure (HP) in the dural sac that forces CSF into the nerve root sheaths. We hypothesize that in patients with TCs, increased spinal hydrostatic pressure is always associated with increased intracranial pressure. This hypothesis of increased cerebrospinal pressure might explain why patients with sacral TCs frequently report distant symptoms, such as headaches and pain in the neck and arms.In this paper, we describe a case report that provides evidence for this hypothesis.A 30-year-old man presented for the first time in our clinic complaining of lower back, leg, thoracic, neck, and arm pain; headaches; and bladder, bowel, and sphincter symptoms.He was born prematurely and suffered cerebral intraventricular bleeding followed by progressive hydrocephalus. Progression was stabilized with acetazolamide and lumbar punctures. At 19 years of age, his head circumference had further increased and he reported back pain and headaches. Fundoscopy showed no papilledema, and lumbar puncture for CSF evacuation improved the headaches and back pain. The former medical team chose not to insert a ventriculo-external shunt.Brain magnetic resonance imaging (MRI) showed significant dilation of all the ventricles. No CSF flow obstruction between the ventricles was observed.Surprisingly, MRI of the lumbar and sacral spine showed multiple large TCs.This case report indicates that hydrocephalus with a patent aqueduct may be associated with TCs because the increased intracranial pressure is transferred to the spinal canal. While increased intracranial pressure causes dilation of the ventricles, the associated increased spinal pressure may cause dilation of multiple spinal nerve root sheaths to form TCs. Furthermore, while the increased volume of the ventricles gradually compresses the neurons and axons of the brain against the bony skull, simultaneously, the increased pressure inside the nerve sheaths may also gradually compress the neurons and axons located inside the dorsal root ganglia and spinal nerves, resulting in neuropathic pain, sensory abnormalities, and neurogenic bladder and bowel symptoms.Hydrocephalus patients reporting neuropathic pain should be screened for the presence of TCs.

European multicentre study on technical success and long-term clinical outcome of radiofrequency ablation for the treatment of spinal osteoid osteomas and osteoblastomas.

To evaluate technical success and long-term outcome of CT-guided radiofrequency ablation (RFA) of spinal osteoid osteomas (OO) and osteoblastomas (OB) in six different European centres. Eighty-seven patients with spinal OO (77) or OB (10) were treated with CT-guided RFA, after three-dimensional CT-guided access planning. Patient's long-term outcome was assessed by clinical examination and questionnaire-based evaluation including 10-point visual analogue scales (VAS) regarding the effect of RFA on severity of pain and limitations of daily activities. Clinical success was defined as a reduction of > 30% in the VAS score and patient's satisfaction. Overall, RFA was technically successful in 82/87 cases (94.3%) with no major complications; clinical success was achieved in 78/87 cases (89.7%). The OO/OB were localized in the cervical (n = 9/3), the thoracic (n = 27/1), the lumbar (n = 29/4), and the sacral spine (n = 12/2). A decrease in severity of pain after RFA was observed in 86/87 patients (98.9%) with a persistent mean reduction of overall pain score from 8.04 ± 0.96 to 1.46 ± 1.95 (p < 0.001) after a median follow-up time of 29.35 ± 35.59months. VAS scores significantly decreased for limitations of both daily (5.70 ± 2.73 to 0.67 ± 1.61, p < 0.001) and sports activities (6.40 ± 2.58 to 0.67 ± 1.61, p < 0.001). In a multicentric setting, this trial proves RFA to be a safe and efficient method to treat spinal OO/OB and should be regarded as first-line therapy after interdisciplinary case discussion.

A simple approach for ultrasound-guided pararadicular injections in the sacral spine: a pilot computer tomography controlled cadaver study.

Injection therapies play an increasingly decisive role in the treatment of lower back pain. Cumulative studies couldshow the benefits of ultrasound-guided instillation procedures in the cervical and lumbar spine. We conducted this study toprovide a new simple sonographic approach for pararadicular injections of the sacral spinal nerves and to prove the feasibilityand accuracy by means of CT and anatomic dissection. Eight ultrasound-guided injections at fourdifferent levels of the sacral spine on a human ethanol-glycerol-embalmed cadaver (S1-S4) were performed. By means ofsonography the sacral foramina were identified and the spinal needles were advanced in "in-plane technique" to the medialmargin of the respective sacral foramen. Subsequently a solution of blue dye and contrast agent were injected. Then CT scansand anatomic dissection of the cadaver were performed to verify the correct placement of the needle tips and to visualize thedispersion of the injected solution in the respective compartment. Altogether a 100% success rate for a correct injectioncould be achieved. CT examination confirmed the correct placement of every needle tip within the intended compartment.Also, the anatomic dissections affirmed the appropriate needle positioning. Moreover, the blue dye dispersion was seen in thecorrect compartments and around the targeted spinal nerves. Although this study was only performed on cadavericmodels, this new sonographic approach for pararadicular injections in the sacral spine allows an easy, precise and unerringneedle placement within the dorsal sacral foramen.

AOSpine-Spine Trauma Classification System: The Value of Modifiers: A Narrative Review With Commentary on Evolving Descriptive Principles.

Study Design:Narrative review.Objectives:To describe the current AOSpine Trauma Classification system for spinal trauma and highlight the value of patient-specific modifiers for facilitating communication and nuances in treatment.Methods:The classification for spine trauma previously developed by The AOSpine Knowledge Forum is reviewed and the importance of case modifiers in this system is discussed.Results:A successful classification system facilitates communication and agreement between physicians while also determining injury severity and provides guidance on prognosis and treatment. As each injury may be unique among different patients, the importance of considering patient-specific characteristics is highlighted in this review. In the current AOSpine Trauma Classification, the spinal column is divided into 4 regions: the upper cervical spine (C0-C2), subaxial cervical spine (C3-C7), thoracolumbar spine (T1-L5), and the sacral spine (S1-S5, including coccyx). Each region is classified according to a hierarchical system with increasing levels of injury or instability and represents the morphology of the injury, neurologic status, and clinical modifiers. Specifically, these clinical modifiers are denoted starting with M followed by a number. They describe unique conditions that may change treatment approach such as the presence of significant soft tissue damage, uncertainty about posterior tension band injury, or the presence of a critical disc herniation in a cervical bilateral facet dislocation. These characteristics are described in detail for each spinal region.Conclusions:Patient-specific modifiers in the AOSpine Trauma Classification highlight unique clinical characteristics for each injury and facilitate communication and treatment between surgeons.

SAT-312 A Rare Case of Metastatic Paraganglioma with Positive SDHB Mutation: An Incidentally Found Silent Monster

Introduction: Although paragangliomas (PG) are derived from extra-adrenal chromaffin cells of sympathetic paravertebral ganglia in the thorax, abdomen, and pelvis, they can also arise from parasympathetic ganglia located along the glossopharyngeal and vagal nerves in the neck and at the base of the skull. Non-secretory PG have a low prevalence, are often silent, and can present as a malignant tumor with mass effects. Symptoms often include: unilateral hearing loss, pulsatile tinnitus, cough, hoarseness, pharyngeal fullness, swallowing difficulty, pain, and/or problems with tongue motion. Case: A 25 year old African American woman presented with 2 yrs of exertional presyncope, night sweats, subjective fevers, 20 lb. weight loss and a nontender enlarging left neck mass. Family history: Mother had thyroid cancer. Physical exam- BMI 21 kg/m2, BP 118/72 mmHg, HR 74, with indurated, fixed, nontender mass in left upper neck, inferior to mandibular angle. Laboratory-Hgb 6.9 g/dl, MCV 71.7, Iron 137 mcg/dl, TIBC 151 mcg/dl, Ferritin 155 ng/ml, CRP 65.20 mg/dl, ESR 122 mm/hr, AST 107 U/l, ALT 7 U/L, Alk Phos 81 U/l. EGD and Colonoscopy-normal. CT scan of neck, abdomen and pelvis: 6.0x3.5x2.7 cm heterogeneously enhancing mass in left neck involving skull base at carotid canal level, within the internal carotid space, causing external compression of left internal jugular vein, with multiple hypervascular lesions in bilateral lungs, liver and spleen, as well as cervical, thoracic, lumbar and sacral spine. Packed red blood cells were transfused. Liver Biopsy-metastatic paraganglioma with SDHB mutation. Laboratory tests- normal plasma catecholamines, thyroid function tests, prolactin, cortisol, ACTH, LH, FSH. A few weeks later, she reported new onset left sided tinnitus, orbital pain and vision changes. MRI Brain/orbit- 10 x 11 mm enhancing lesion centered in left cavernous sinus near orbital apex without intra or extraconal lesion. Chemotherapy was started with vincristine, cyclophosphamide and dacarbazine. After 12 weeks of chemotherapy, the left neck mass size decreased, tinnitus, and vision changes resolved. She was referred for genetic counseling and multidisciplinary care. Discussion: Our patient had malignant head and neck PG with SDHB mutation. Mutations in the gene encoding SDH subunit B (SDHB) can lead to metastatic disease in ≥ 40% of patients, are frequently familial, and are associated with other malignancies (renal cell carcinoma, pituitary adenoma, breast and thyroid cancer). Although there are current guidelines regarding diagnosis and management of non-malignant secretory paraganglioma/pheochromocytoma, screening and management of metastatic disease is not clear. Therefore, it is important to have a low threshold of suspicion for early diagnosis. Provider awareness and education regarding diagnosis and management is needed.

TCTAP C-077 Ipsilateral AMI with Shock Plus Contralateral Stumpless Chronic Total Occlusion

### Patient Initials or Identifier Number Mr. M ### Relevant Clinical History and Physical Exam Chief complaint: acute onset chest tightness for half hour, Past history: sacral spine cyst, s/p operation, Family history of coronary artery disease, that patient's brother has a medical history of

Isolated fourth ventricle haemorrhage: “think beyond intracranial source’’ unusual presentation of lumbosacral spine arteriovenous malformation presentation

Spinal arteriovenous malformations (SAVMs) are rare vascular lesions and account for about 4% of primary intraspinal masses. Since SAVMs can involve any location along the spinal column and produce a host of different problems, the symptoms are extremely variable. There are few reports of simultaneous cerebral SAH and intraventricular hemorrhage (IVH) following rupture of a spinal AVM (SAVMs). Herein, we present a rare case of Lumbo Sacral spine arteriovenous malformation, which clinically manifests as sudden onset of severe headache and vomiting due to isolated fourth ventricle Hemorrhage (IVH) without cerebral subarachnoid hemorrhage.

A case of mucolipidosis II / manifested as chondrodysplasia punctata in a second trimester fetus

The case of mucolipidosis II / in a second trimester fetus is presented. At the ultrasound examination at 20 weeks of gestation intrauterine growth restriction, abnormal profile with flattened nose, polyhydramnios and premature maturation of the placenta were detected. Autopsy subsequent to the termination of pregnancy revealed intrauterine growth restriction, shortening of the lower limbs, pronounced facial dysmorphism. The radiograph showed a significant shortening of the long tubular bones, sclerosis of the skull base, reduced mineralization of the bones of the facial skull, calcifications in the vertebral bodies of the cervical and sacral spine, proximal epiphysis of the left humerus and femurs, heel and talus. Microscopic examination of the placenta revealed pale-colored villi with diffuse pronounced vacuolization of syncytiotrophoblast cells, Hofbauer — Kashchenko cells, and unvillous trophoblast, focal calcification of the basement membranes of the villi in the form of linear deposits. A molecular genetic study revealed a compound heterozygous carriage of the mutations p.Asp919GlufsTer21 and p.Arg1189Ter in 14 and 19 exons of the GNPTAB gene and the diagnosis mucolipidosis II alpha/beta was established.

Lumbosacral radicular pain during micturition, defecation or orgasm.

The objective of this study was to describe, in a cohort of patients followed for bladder, bowel or sexual dysfunctions, the occurrence of radicular pain during micturition, defecation and/or orgasm. The study included all patients referred in our neuro-urology department and who suffered from radicular pain before, during or after micturition, defecation and/or orgasm. Data included demographic and medical variables, urodynamic and perineal electromyographic diagnosis. A total of 30 patients (men: 70%, mean age 45.4±11.8,) complained of radicular pain before, during or after orgasm (51.4%), micturition (34.3%), or defecation (14.3%). In 30% of cases, radiculopathy was found and was predicted by micturition pain. Other pathologies were as follows: vertebral (16.5%), pelvis and sacral (16.5%), inflammatory central nervous system (10%) lesions and peripheral neuropathies (6.7%). Neurological level of injury was between the lumbar and the sacral level. All spinal cord lesions were lesions of the conus medullaris. Patients also complained of lower urinary tract symptoms (70%), sexual (63.3%) and bowel (60%) disorders. In most cases, the urodynamic diagnosis was neurogenic bladder with peripheral abnormalities and the electromyographic diagnosis was distal neuropathy. Radicular pain occurring during micturition, defecation or orgasm is a rare condition. The most common underlying lesion seems to be radiculopathy, from lumbar to sacral spine. The presence of these symptoms, in the absence of any known neurological condition, should suggest the practitioner a radiculopathy in most of the cases. In consequence, appropriate additional tests should be offered to these patients. Few data are available on sciatica during micturition, defecation or orgasm. This study underlines the need for appropriate tests if a patient complaint from this type of symptom. Indeed, the most common underlying lesion is a radiculopathy but can also be a lesion of conus medullaris.

A systematic comparative outcome analysis of surgical versus percutaneous techniques in the management of symptomatic sacral perineural (Tarlov) cysts: a meta-analysis.

Symptomatic perineural or Tarlov cysts (TCs) are a rare cause of chronic low-back pain. Given the rarity of the disease, there is no literature consensus regarding the optimal management of these cysts. The authors conducted a systematic comparative outcome analysis of symptomatic TCs treated with surgery (group A, 32 studies, n = 333) or percutaneous interventions (group B, 6 studies, n = 417) analyzing the demographic characteristics, baseline characteristics of the cysts, clinical presentations, types of interventions, complication rates, and the recurrence rate in both treatment groups. The literature search was performed using the PubMed, MEDLINE, Cochrane, and Ovid databases up to 2018. The MeSH search terms used were "Tarlov cyst," "sacral perineural cyst," "sacral nerve root cyst," "meningeal cyst of the sacral spine," "extra meningeal cyst with spinal nerve root fibers," "spinal extradural arachnoid pouch," and "cyst of the sacral nerve root sheath." The authors used statistical tests for two proportions using the "N-1" chi-square test with the free version of MedCalc for Windows for comparison among the groups. Overall symptomatic improvement was reported in 83.5% of patients in both groups; however, exacerbation of preprocedural symptoms was significantly higher in group B than group A (10.1% vs 3.3%, p = 0.0003). The overall complication rates in the surgical and nonsurgical groups were 21% and 12.47%, respectively. Transient sciatica was the most common complication in both groups (17% vs 8%, respectively; p = 0.017). The incidence of cyst recurrence was much lower in group A than group B (8% vs 20%, p = 0.0018). The mean follow-up duration for the surgical group was 38 ± 29 months (25 studies, n = 279), while that for the nonsurgical group was 15 ± 12 months (4 studies, n = 290) (p < 0.0001). The authors noted that although the surgical interventions were associated with higher postprocedural complication rates, long-term efficacy and success in terms of cyst resolution were superior following surgery compared to percutaneous procedures in the management of symptomatic TCs. There was no difference in symptom recurrence with either of the techniques.

Reliability of an Intraoperative Radiographic Anteroposterior View of the Spinal Midline for Detection of Pedicle Screws Breaching the Medial Pedicle Wall in the Thoracic, Lumbar, and Sacral Spine

The purpose of this study was to determine the sensitivity and specificity of using the spinal midline (M line) on a radiographic anteroposterior (AP) view for detecting pedicle screws (PSs) breaching the medial pedicle wall. We retrospectively reviewed 145 patients who underwent fusion surgery using PSs between January 2006 and May 2017. We defined the M line as a line that connected the upper and lower spinous processes through the fixed vertebrae. The M line was positive if the tip of the PS crossed the M line. The reference standard was a computed tomography scan. The reliability of the M line was examined. The subjects included 145 patients (70 men and 75 women; mean age, 63.4 years). A total of 599 PSs were examined. Most cases were because of spondylolisthesis (66.9%). Most screws were inserted at a lower lumber level (77.6%). Analysis of the diagnostic accuracy of the M line yielded a sensitivity of 74.1% and a specificity of 95.3%. In addition, the positive predictive value of the M line was 42.6%, and the negative predictive value of the M line was 98.7%. Assessment of the M line via an intraoperative radiographic AP view is a simple, readily available, complementary method for detecting PSs that have breached the medial pedicle wall in the thoracic, lumbar, and sacral spine. In particular, the M line has a strong negative predictive value, which is much more meaningful.

Freehand pedicle screw fixation: A safe recipe for dorsal, lumbar and sacral spine.

Objective:To determine outcome of freehand pedicle screw fixation for dorsal, lumbar and sacral fractures at a tertiary care centre in the developing world.Methods:A retrospective review was performed of 150 consecutive patients who underwent pedicle screw fixation from January 1, 2012 to 31st December 2017. A total of 751 pedicle screws were placed. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography.Results:Among the total 751 free hand placed pedicle screws, four screws (0.53%) were repositioned due to a misdirected trajectory towards the disc space. six screws (0.79%) were identified to have cause moderate breach while four screws (0.53%) cause severe breach. There was no occurrence of iatrogenic nerve root damage or violation of the spinal canal.Conclusion:Free hand pedicle screw placement based on external landmarks showed remarkable safety and accuracy in our center. The authors conclude that assiduous adherence to technique and preoperative planning is vital to success.

Current concepts and an update on the surgical management of metastasis to the sacral spine

This review article endeavors to provide an update on the current concepts pertaining to the presentation, investigation, and management of sacral metastases. A review of the English language literature from 1995 to 2015 was undertaken. PubMed electronic database, SCOPUS, EMBASE, Medline OVID, and Cochrane database were searched to identify relevant studies using the terms “sacral metastases” and “metastatic sacral tumours.” Sacral metastasis can present in a variety of ways. Pain in the sacral region can be associated with neurology and mechanical instability. Multidisciplinary involvement is crucial to thoroughly work up the patient. This involves a variety of imaging modalities. Radiotherapy is often used as the first-line treatment. Surgical intervention is based on tumor location, infiltration of surrounding structures, expected outcomes based on primary malignancy, and pelvic stability. Adjuvant cryosurgery and radiosurgery have demonstrated promising results. This is a challenging entity to appropriately diagnose and treat. An appreciation of the disease stage, the clinical burden, and the implications for the individual patient are necessary to deliver patient-centered care.

Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients.

High accuracy in intraoperative computed tomography (iCT) navigation utilizing an intraoperatively acquired dataset for screw placement in the spine has been reported in the literature. To further improve the accuracy and counteract any intraoperative movement of predefined registration points, we introduce an iCT point-to-point navigation, where marker screws are inserted intraoperatively to increase patient safety. In all, 1054 patients who underwent iCT point-to-point navigation for lateral mass and pedicle screw placement were retrospectively analyzed between 09/2005 and 09/2016. Implant-related complications such as screw misplacement, screw loosening, and revision rate were determined. Furthermore, we investigated the rate of complications and the clinical outcome. In total, 6059 screws were inserted in 1054 patients. There were 553 (52.5%) female and 501 (47.5%) male patients. Average age was 63.5years, mean BMI 27.5 (SD 13.9). Here, 1427 (23.5%) screws were inserted in the cervical, 995 (16.4%) in the thoracic, 3167 (52.3%) in the lumbar, and 470 (7.8%) in the sacral spine. Eight patients required a revision procedure for screw misplacement (0.8%). Total screw misplacement rate was 0.3% (16/6059). With the use of reference markers in iCT-based, spinal, point-to-point navigation, we achieved a high accuracy of screw placement with a low revision rate (0.8%) and a total screw misplacement rate of 0.3%.