Introduction: The vertebral column functions to support the body and protect the spinal cord. Hemivertebra is a congenital disorder due to the failure of the formation of part of the vertebral corpus and often causes scoliosis. Scoliosis due to the hemivertebra is progressive, can cause spinal imbalance and severe deformity. The diagnosis can be established through prenatal ultrasound, X-rays, CT scans, and MRIs. X-rays are generally used as an initial examination because they are easily accessible, but they have limitations in assessing complex deformities. CT scans with three-dimensional reconstruction provide a detailed picture of vertebral structure for preoperative planning, while MRI allows for a comprehensive evaluation of neural axis abnormalities without radiation exposure. Case Report: A 14-year-old boy came to dr. Slamet Garut Hospital with complaints of asymmetrical back accompanied by a growing lump and right back pain since the last three years. Patients also complain of getting tired easily and sweating quickly during activities. The history of the disease shows pulmonary tuberculosis at the age of six months which has been treated completely. History of growth and development is obtained with delays in motor and speech development. MSCT-scan thoracoumbal Th1 to os sacrum with contrast showed congenital severe kyphoscoliosis due to the fully segmented type hemivertebra in Th12, with no peccule and left costa 12, as well as suspicion of narrowing of the posterior spinal canal. Conclusions: The patient was diagnosed with congenital severe kyphoscoliosis due to hemivertebra fully segmented Th12 accompanied by pedicle and costa abnormalities. 3D/MSCT CT and MRI are more accurate than X-rays in assessing complex deformities and nerve structures. The definitive management recommended is hemivertebrectomy to prevent the progression of deformity.

Background Acquired dermal melanocytosis (ADM) usually affects the face, most often as acquired bilateral nevus of Ota-like macules (ABNOM). Extrafacial cases are rare and remain poorly characterized.Objective To report a rare case of acquired nevus of Ito on the neck and review the literature on extrafacial ADM.Methods We conducted a comprehensive search of PubMed and Google Scholar from 1977 onward to identify all reported cases of extrafacial ADM. Clinical and histopathological features were extracted and analyzed.Results Seventy-four cases were identified, including our patient. Lesions predominantly involved the back, upper extremities, and sacral region. Only three cases, including ours, involved the neck. Histopathology consistently showed dendritic melanocytes in the dermis, with many cases staining positive for S100, HMB-45, and MART-1.Conclusion Extrafacial ADM is an uncommon variant with overlapping histologic and pathophysiologic features to facial forms. This report expands the limited literature and highlights the importance of considering ADM in the differential diagnosis of new-onset dermal pigmentation on the neck and other non-facial sites.

ABSTRACT We describe the first hadrosaurid fossils from the Upper Cretaceous Nenjiang Formation (early Campanian) in the Songliao Basin, Northeast China. The material comprises an isolated tooth, three dentary fragments, and several fragmentary postcranial bones consisting of dorsal, sacral, and caudal vertebrae, as well as fragments of the pubis, ischium, and fibula. Morphological analyses indicate that the postcranial material can be assigned to Lambeosaurinae. These lambeosaurine remains represent a rare record of the early divergence of this group, supporting the hypothesis of an Asian origin for lambeosaurines and their subsequent dispersal to North America. This study expands the known geographic and temporal distribution of hadrosaurids, highlights the significance of the Nenjiang Formation in documenting dinosaur diversity, and provides valuable insights into the terrestrial ecosystems of the Songliao Basin during the Late Cretaceous.

Introduction: Pressure sore are localized skin and soft tissue damage typically occurring over bony prominences due to impaired blood supply from sustained pressure. This study aims to review the clinical profile patients with pressure sore and the type of management of pressure sore in regional referral center of western Nepal. Methods: This retrospective, observational study was conducted at the Department of Burns, Plastic and Reconstructive Surgery, Charak Memorial Hospital, Pokhara, from January 2023 to December 2024. Ethical approval was obtained from National Health Research Council on 16 February 2025 (Reference no:1839). The study included all patients regardless of age and gender who were treated for pressure sores during the study period, with complete medical records. Patient demographics, sore characteristics, predisposing factors, and treatment modalities were analyzed. Results: There were 21 patients with 42 pressure sore wounds, included with mean age 45.14±25.54 years (range: 16-92 years). Of all patients 16 (79.19%) were male and 16 patients (76.19%) were patients from outside Pokhara Valley. Spinal cord injury was present in 12 (57.14%) patients. The sacral and trochanteric regions were affected with 14 (33.33%) wounds each. There were 26 (61.90%) wounds classified as National Pressure Ulcer Advisory Panel Stage IV. Surgical management was performed in 14 (66.67%) patients with Local flap was used to reconstruct 12 (50%) of the wounds. Conclusions: Pressure sore in this population predominantly affected middle aged males with spinal cord injuries, presenting with advanced-stage wounds. Local pattern flap was the most common method of soft tissue coverage.

Objective Anatomical variations in the sacrococcygeal region can lead to complications such as accidental dural puncture during caudal block. This study aimed to determine the prevalence of sacrococcygeal anatomical variations using ultrasonography and to evaluate the necessity of ultrasound guidance in sacral block procedures. Methods Ultrasound findings of sacrococcygeal anatomy were validated against magnetic resonance imaging (MRI). A detailed ultrasound protocol was subsequently applied to assess sacrococcygeal anatomy in pediatric patients. Results Ultrasound and MRI demonstrated strong concordance in evaluating sacrococcygeal anatomy. The most common anatomical variation was a low-lying dural sac (16.2%), followed by incomplete sacral cornua (4.9%). The dural sac termination level was inversely associated with age (odds ratio: 0.996, 95% CI: 0.945–0.987; p < 0.001). Other variations included abnormal coccyx curvature (4.3%), sacral skewness (3.8%), and sacral hiatus atresia (1.1%), with no pathological abnormalities detected. Conclusion Comprehensive ultrasound scanning effectively identifies anatomical variations in the sacrococcygeal region of pediatric patients, which are highly prevalent. Routine preprocedural ultrasound examinations and ultrasound guidance during caudal block procedures are strongly recommended to enhance safety and accuracy.

Vertically displaced sacral fractures are complex injuries commonly resulting from high-energy trauma and often complicated by neurological deficits, pelvic instability, and leg length discrepancy. When managed conservatively or under emergent conditions, they are prone to malunion. Surgical correction in these cases is technically demanding due to the intricate sacral anatomy and proximity of neurovascular structures. A 26-year-old female war victim had a malunited, vertically displaced left sacral ala fracture. Initial treatment with an anterior external fixator failed to address the vertical displacement. Four months after the injury, the patient presented with severe pelvic pain, inability to walk, and a 6-cm leg length discrepancy. Neurological examination revealed decreased dorsiflexion strength and sensory deficits on the left foot. A 3-stage, single-setting surgical correction was performed: anterior pelvic osteotomy using the Stoppa approach; posterior sacral osteotomy and reduction via a posterior midline approach; and triangular osteosynthesis involving lumbo-pelvic distraction and transverse fixation. The anterior osteotomy site was subsequently stabilized with a reconstruction plate. Intraoperative neuromonitoring was utilized throughout the procedure. The surgery reduced the pelvic asymmetry and reduced the leg length discrepancy from 6 cm to approximately 1 cm. Postoperatively, the patient maintained her preoperative motor status, with dorsiflexion strength of 3/5 initially, improving to 4/5 within 3 weeks. Sensory deficits remained stable without further deterioration. She was mobilized with nonweight-bearing ambulation immediately postoperatively, progressing to full weight bearing by the third postoperative week. One month after surgery, she developed a superficial wound infection that resolved with outpatient wound care and oral antibiotics. At the 6-month follow-up, the patient was walking independently without assistive devices. Radiographs confirmed stable fixation and maintenance of reduction with satisfactory signs of bone healing. No neurological deterioration or implant-related complications were observed. Clinical and radiographic assessments supported a successful outcome. This case illustrates the feasibility and efficacy of a comprehensive, single-session surgical approach for treating a vertically displaced sacral fracture malunion. Triangular osteosynthesis combined with sacral osteotomy provides biomechanical stability and enables early mobilization. Multistage intraoperative positioning and careful dissection are critical for successful outcomes. Malunited vertically displaced sacral fractures are uncommon but highly disabling, often associated with pelvic asymmetry, leg length discrepancy, and neurological deficits. Surgical correction is challenging because of complex sacral anatomy and proximity to critical neurovascular structures. The successful restoration of alignment, early mobilization, and functional improvement in this case highlight the feasibility of this approach. This report offers practical technical guidance of a single-session, staged anterior-posterior osteotomy and triangular osteosynthesis for surgeons managing similarly complex sacral malunion deformities.

Balance is referred to as a state of equilibrium where forces of agonist and antagonistic muscles are equal. This is particularly relevant in the practice of Goju-Ryu Karate-Do, a martial art style with combinations of hard and soft techniques. Particularly, karate stances not only depend on technical aspects but also on the ability to achieve a centered posture. In this narrative review, we aim to integrate the existing knowledge about alignment parameters of the spine to various stances in Goju-Ryu Karate-Do to improve biomechanical understanding, allow technical modifications, and consequently enhance positive training experience. Balance is constantly challenged during the interplay of accelerated movements and subsequent controlled postures (Japanese: “Kamae”). This requires continuous neuromuscular coordination to maintain the body’s equilibrium. In particular, the body’s center of gravity, which is located around the second sacral vertebra in a standing position, needs to be kept within Dubousset’s “efficiency cone” for low energy consumption and minimal fatigue. This state is primarily maintained by aligning the spine, the pelvis, and the lower extremities, which is a result of complex biomechanical interactions of various spinopelvic parameters. Applying these concepts of Dubousset to stances in Goju-Ryu Karate-Do helps to explain why during the aging process or natural degeneration, technical modifications are needed to guarantee an optimal training experience in senior or disabled practitioners of Karate-Do. Biomechanical parameters of the spinopelvic axis are crucial in mastering the art of Goju-Ryu Karate-Do. Only with a balanced stance and an optimally situated center of gravity, a block or attack may be successful and movement strategies effective. However, technical modifications of stances must be considered in aged or disabled karateka to allow a sustained training experience.

Back pain in horses is a frequent musculoskeletal issue that affects performance and welfare. Magnetotherapy has been proposed as a complementary, non-invasive treatment to reduce pain and support soft tissue recovery, but studies in horses remain limited. This pilot study aimed to evaluate the effects of low-frequency pulsed magnetic field therapy on horses with hypersensitivity to palpation along the longissimus dorsi muscle. Four recreational horses participated in a 10-session magnetotherapy program, with changes assessed using palpation, neck flexibility tests, heart rate measurements and thermal imaging. Results showed a reduction in pain sensitivity and muscle tension, particularly in the withers, thoracic, lumbar and sacral regions. Heart rate decreased after treatment, which may indicate a relaxing effect. Thermal imaging confirmed that magnetotherapy did not increase surface temperature, confirming its non-thermal nature. No adverse effects or swelling were observed in any of the horses. These findings provide preliminary data from this pilot study, suggesting that magnetotherapy may be a beneficial adjunct in the treatment of back pain in horses, promoting relaxation and pain relief without inducing tissue heating. Further research on larger populations with a negative control group is needed to validate these findings and support broader clinical application.

ABSTRACT The fossil record of titanosaur sauropods for the Upper Cretaceous of the Neuquén Basin is remarkably extensive. However, for the Bajo de la Carpa Formation (Santonian) only five nominate species are recorded (Rinconsaurus caudamirus, Bonitasaura salgadoi, Traukutitan eocaudata, Overosaurus paradasorum, and Inawentu oslatus), the latter two coming from the Cerro Overo-La Invernada (CO-LI) area. Here we present a new titanosaur sauropod from La Invernada, Yeneen houssayi gen. et sp. nov. (MAU-Pv-LI-538). The new species is characterised by a series of distinctive features in dorsal, sacral and caudal vertebrae. Phylogenetic analysis indicates that Yeneen is closely related to Narambuenatitan and Overosaurus, as a basal member of an unnominated clade (called ‘Clade A’) of derived non-lithostrotian saltasauroids. The evidence provided by the Cerro Overo – La Invernada sauropod titanosaur fauna suggests that, during the Santonian, species diversity was relatively high and that at least two lineages coexisted: Collossosauria and Saltasauroidea. This finding makes the CO-LI area the one with the greatest diversity of titanosaurs for the Santonian of the Neuquén basin (as it is also for abelisaurid theropods), which makes it an exceptional area to understand the evolution of dinosaur faunas for this period.

A 31-year-old man presented with a 3-month history of moderately pruritic, salmon-coloured plaques forming a continuous linear column from the upper chest to the lower abdomen anteriorly and from the nape of the neck to the sacral region posteriorly. Additional findings included erythematous plaques with coarse lamellated scale on the forehead and eyebrows, and waxy palmoplantar keratoderma. Histopathology showed psoriasiform epidermal hyperplasia with alternating ortho- and parakeratosis and a superficial perivascular lymphocytic infiltrate, consistent with type I pityriasis rubra pilaris (PRP). Treatment with ustekinumab resulted in marked clinical improvement. This unusual linear midline presentation broadens the recognised clinical spectrum of type I PRP.

Background: The sacral hiatus is the lowest unfused part of the sacral lamina of the sacrum. The external characteristics of the sacral hiatus can vary greatly, including its length, shape, anteroposterior (AP) length, transverse length, and the specific spinal level at which its apex is located. In procedures such as caudal epidural anesthesia (CEA), where a precise anatomical understanding of the sacral hiatus is crucial, this heterogeneity possesses clinical significance. The study aimed at analyzing sacral hiatus morphometry, including length, shape, AP and transverse diameters, and apex vertebral level, and to mitigate risks associated with CEA based on the current study results. Methodology: This descriptive study was conducted on 300 samples, including 100 cadaveric dry sacra (51 males and 49 females) and 200 computed tomographic sacral images (114 males and 86 females) over 24 months. The study assessed the length, transverse length, AP depth, overall morphological configuration of the sacral hiatus, and specifically, the vertebral level where its apex is located. Both physical examinations of cadaveric dry specimens and computerized tomography imaging techniques were utilized. Results: According to the current study, the most common form of the sacral hiatus was an inverted U-shape (51%–53%), followed by an inverted V-shape. The craniocaudal length of the hiatus varied from 9 mm to 103 mm, while the AP depth ranged from 3 mm to 7 mm. The apex of the hiatus was most frequently located at the S4 level (52%–54%), followed by S3, S2, and S5. Conclusion: The sacral hiatus is crucial in procedures, especially those involving surgical approaches to anesthetize the regions supplied by the sacral plexus. It serves as the primary access point for CEA and injections. The morphometric variability in the sacral hiatus and varied level of its apex, particularly high hiatus might pose a risk of injuring the meninges and it also demarcates the site at which successful Caudal epidural anesthesia can be given. Improper identification of the hiatus location or misplacement of surgical instruments may lead to inadvertent nerve injury.

Introduction: Lumbosacral dislocation revealing cauda equina syndrome is relatively uncommon. Although various treatment strategies have been reported, no consensus has been reached regarding the best surgical approach. Case Presentation: We report the case of a 35-year-old patient with no previous history, admitted for lumbosacral trauma with acute urine retention and neurological deficits in both legs. The CT scan revealed an anterolisthesis of the 5th lumbar vertebra (L5) on the 1st sacral vertebra (S1). The patient was operated on with a posterior approach followed by ALIF. The patient’s neurological recovery was almost complete. Conclusions: Lumbosacral dislocation is a rare cause of compression of the cauda equina. This case report presents our first experience with a posterior approach followed by an anterior ALIF approach between L5 and S1.

This study aims to investigate how varying shoulder movement speeds affect spinal mobility to enhance understanding of the trunk's adaptive response to these perturbations. Eleven healthy participants were fitted with motion markers placed on the bilateral shoulders, upper extremities, and the spinous processes of the 8th thoracic vertebra (T8), 4th lumbar vertebra (L4), and the posterior superior iliac spine, representing the 2nd sacral vertebra (S2). Each participant performed bilateral forward shoulder elevation in the sagittal plane at three different speeds (natural, fast, and slow) in a randomized order. Each speed condition included five repetitions, with the middle three repetitions used for analysis. The peak-to-peak displacement and excursion of T8, L4, and S2 during the ascending and descending phases of shoulder elevation were recorded. Repeated measures one-way analysis of variance (ANOVA) and the Friedman test were applied to compare the effects of the three speeds. Significant differences were observed between the fast and slow speeds in the peak-to-peak displacements of T8 and L4 during the descending phase, as well as in the T8 excursion across the full range of forward shoulder elevation, or 31%, 24%, and 26% increase, with p-values of 0.045 (ES = 1.053), 0.042 (ES = 1.019), and 0.028 (ES = 1.174), respectively. No significant differences were detected at the S2 level. Spinal mobility during forward shoulder elevation was observed at fast speed, especially during the descending phase at the thoracic and lumbar levels. These speed-dependent changes are clinically critical, influencing movement control and trunk injury risk, especially during descent of forward shoulder elevation. The speed of shoulder movement should be considered during physical examination and intervention.

Abstract Introduction Patients with provoked vestibulodynia symptoms have a significantly higher prevalence of interstitial cystitis (IC) symptoms compared to the general population. The association is bidirectional, with many patients diagnosed with one condition also experiencing symptoms of the other. Systematic reviews and case-control studies reveal a positive association between provoked vestibulodynia and IC, with shared comorbidities and overlapping causes. Recognizing the overlapping symptoms is important for diagnosis and management, as treating one condition may improve symptoms of the other. Objective To better understand the mechanism by which a woman with devastating, unrelenting IC symptoms for 14 years, failing all IC management strategies, was successfully treated for her IC symptoms by vestibulectomy. Methods A 49 YO woman presented with persistent pain/pressure/discomfort in the bladder/pelvic region, worsening with bladder filling, rarely relieved by urination, with associated urinary urgency, frequency, nocturia and urinary incontinence, as well as a history of lifelong entry dyspareunia. She underwent a biopsychosocial assessment including psychosexual history, hormonal blood tests, and vulvoscopy with vestibular anesthesia testing (VAT) performed by applying benzocaine 20%/lidocaine 8%/ tetracaine 6% to the entire vestibule. Results The following treatments for IC were unsuccessful in reducing bladder pain symptoms: i) lifestyle modification, ii) mind-body interventions, iii) cognitive behavioral therapy, iv) oral pentosan polysulfate sodium, v) hydrodistension of the bladder and vi) intravesical bladder instillation therapies with dimethyl sulfoxide (DMSO), sodium hyaluronate and botulinum toxin A. Vulvoscopy revealed positive cotton swab testing throughout the entire vestibule, and pain when the vestibule was stroked with a cotton swab. VAT resulted in temporary resolution of pain in the vestibule as well as elimination of all bladder symptoms for the first time in 14 years. Hymenal biopsy confirmed excess density of mast cells and nerve endings consistent with neuroproliferative vestibulodynia. Since undergoing a complete vestibulectomy with vaginal advancement flap reconstruction, the patient reports absence of all IC symptoms as well as absence of entry dyspareunia. Conclusions We hypothesize that central cross-sensitization at the conus medullaris (sacral spinal cord) is the basis for the overlap between IC and provoked vestibulodynia symptoms. In women with provoked vestibulodynia, vestibular sensations via pelvic nerve visceral afferents pass through the S2-S4 sacral foramina and ascend in the cauda equina to synapse at the second-order spinothalamic neurons in the conus medullaris. Bladder afferents, also via the pelvic nerve, synapse at the spinothalamic neurons in close proximity to the vestibular afferents, as the diameter of the entire human sacral spinal cord is less than 1 cm. This patient's 14 year-long abnormally high pelvic nerve afferent activity from her bladder hyperesthesia and her vestibular dyspareunia likely produced chronic inflammation of the spinothalamic neurons. Thus, stimulation of vestibular afferents could trigger activation of bladder-related spinothalamic neurons and conversely, stimulation of bladder afferents could trigger activation of vestibule-related spinothalamic neurons. This type of phenomenon, which is termed central cross-sensitization at the conus medullaris, likely occurs more often than realized and fully explains how treatment of the underlying provoked vestibulodynia, without any treatment of the IC, resulted in complete resolution of bothersome IC and dyspareunia symptoms. Disclosure No

Background/Objectives: A caudal epidural steroid injection (CESI) is a widely used technique for managing low back and lower extremity pain due to its relative ease and safety. However, cephalic spread of the injectate may be limited by the long distance from the sacral hiatus and by increased intra-abdominal pressure caused using conventional abdominal pillows during prone positioning. This study aimed to investigate whether an eleven-bar cushion could facilitate higher cephalic spread of contrast medium during CESI compared to a conventional pillow. Methods: This retrospective study was approved by the Institutional Review Board (IRB number: AJOUIRB-DB-2025-103). Data from 76 patients, who underwent CESI between January 2023 and March 2024, were analyzed. Patients were divided into two groups the eleven-bar group (n = 38) using a pelvic eleven-bar cushion and the pillow group (n = 38) using a conventional pillow. Fluoroscopic images were reviewed to identify the highest vertebral level reached by the injectate and the number of nerve roots visualized. Visual analogue scale (VAS) scores before and one month after the procedure were also assessed. Statistical analyses included Mann–Whitney U tests, linear regression, and Poisson regression. Results: Baseline demographic characteristics were similar between groups. The cephalic spread of contrast medium was significantly higher in the eleven-bar group compared with the pillow group (median level L3/4 vs. L4/5, p = 0.0002). No significant differences were observed in the number of nerve roots reached or in the VAS score improvement between groups. Conclusions: The eleven-bar cushion facilitated greater cephalic spread of contrast medium during CESI compared with a conventional pillow. Although this technique did not affect nerve root distribution or pain reduction outcomes, it may represent a useful positioning strategy to enhance drug delivery to higher lumbar levels during caudal epidural injections.

Unilateral biportal endoscopy resection for benign neurogenic tumors of sacral canal: Preliminary exploration

Approximately 1% of skin cancers occur secondary to chronic inflammation, and approximately 95% of these are squamous cell carcinomas (SCC) with a metastasis rate of 20-30%. This case report describes the treatment of a 38-year-old male patient with paraplegia and with a history of operated meningomyelocele and congenital hip dysplasia who was admitted to the emergency service of the Basaksehir Cam ve Sakura City Hospital (Istanbul, Turkey) with complaints of bleeding, discharge and pain from a hard-to-heal (chronic) pressure ulcer (PU) in the right gluteal region. The patient had a haemorrhagic and ulcero-vegetant mass/wound of approximately 20×20cm with vegetative satellite lesions located in the right gluteal region extending to the sacral region. Acinetobacter baumannii was growing in the wound culture and appropriate antibiotherapy was initiated followng the recommendation of the infectious diseases clinic. The patient was started on a protein-rich diet, with parenteral paracetamol and non-steroid anti-inflammatory drugs for wound care and pain relief. Pathological examination of the tissue biopsy detected SCCs. According to the pelvic magnetic resonance imaging and positron emission tomography-computed tomography results, the mass was considered inoperable and radiotherapy was administered for wound palliation with the help of the radiation oncology clinic. After 13 sessions of radiotherapy, haemorrhage of the ulcer ceased and the mass showed minor regression. This case report demonstrates that it is important to follow-up on patients with hard-to-heal PUs who are fully or partially bedbound. This can be performed by home health services or family physicians in primary care. If the treatment process is prolonged in palliative care patients with hard-to-heal wounds, requesting further examinations when malignant transformations are observed may create the opportunity for an early diagnosis, which can improve their quality of life. Declaration of interest: The authors have no conflict of interest.

Background: Giant sacral schwannomas present a significant surgical challenge, often requiring extensive resections that compromise neurological function and sacropelvic biomechanics. Conventional approaches frequently necessitate sacral bone sacrifice, resulting in the deafferentation of key pelvic stabilizers and subsequent long-term functional deficits. This study introduces the novel single-posterior "Sacral Frame Technique," designed to preserve the lateral sacral bone margin and optimize functional reconstruction. Methods: We describe the surgical technique and report on a case of a 55-year-old female with a giant sacral schwannoma extending into the spinal canal and presacral space. The resection was performed via a combined trans-sacral and extrasacral approach, employing an intralesional piecemeal strategy to maintain the lateral sacral bone margin. The gluteus maximus muscles, along with the sacrotuberous and sacrospinous ligaments, were meticulously reattached to their natural insertion sites on the preserved bone. Clinical and radiological outcomes were evaluated at six months post-operatively. Results: Complete tumor resection was achieved without post-operative neurological deficits or sphincter dysfunction. The patient achieved early mobilization, returned to pre-operative activity levels, and showed no evidence of sacropelvic instability at the six-month follow-up. Post-operative imaging confirmed complete tumor clearance and the structural integrity of the preserved sacral bone margin. Conclusions: The "Sacral Frame Technique" offers a potential strategy for the safe and effective resection of giant sacral schwannomas. By prioritizing the preservation of the lateral sacral bone margin, the technique facilitates the anatomical reattachment of pelvic stabilizers, potentially mitigating long-term biomechanical deficits. Further studies with larger cohorts are warranted to fully validate these findings and establish the broader applicability of this bone-preserving approach.

Large defects of the posterior trunk after soft tissue sarcoma resection represent a challenge in reconstructive surgery. Coverage with musculocutaneous flaps or free flaps is often associated with donor site morbidity and functional deficits. With increasing popularity, the clinical indications of locoregional perforator flaps have been expanded to defects of the back. In the present study, the use of various perforator propeller flaps for oncologic reconstruction of large soft tissue defects of the posterior trunk is evaluated. Between 2014 and 2023, perforator propeller flaps were performed in 23 patients for reconstruction of large soft tissue defects after sarcoma resection in different regions of the posterior trunk. Soft tissue defects after wide resection of soft tissue sarcoma of the back comprised the cervical, thoracic, lumbar, and sacral regions. Donor sites included perforator propeller flaps of the posterior intercostal artery, lumbar artery, and superior gluteal artery vascular territories. The dimensions of the soft tissue defects of the flaps were 166.6 ± 17.3 cm2. All perforator propeller flaps survived. Revision surgery was required in two patients (partial necrosis of flap tip due to hematoma, n = 1; infected seroma with impaired wound healing, n = 1). During the follow-up (range 6 months-8 8 years) no donor site morbidities or functional deficits were noted. Furthermore, aesthetic results showed excellent contour reconstruction and all patients were satisfied with the surgical outcome. In our experience, perforator flaps represent a safe, versatile and reliable option to resurface large posterior trunk defects following oncological resection.

Background. Fibromyalgia (FM) is a chronic widespread pain condition associated with multiple and heterogeneous systemic manifestations. It is currently regarded as a paradigmatic example of nociplastic pain, specifically a pain not attributable to direct nociceptive stimuli or neuropathic mechanisms, but rather to altered pain modulation processes due to peripheral and central sensitization (hyperalgesia and allodynia). FM may therefore present as a primary condition or coexist with other disorders that can influence its onset, course, and activity. We report two clinical cases of patients with refractory FM in whom an comprehensive diagnostic assessment revealed underlying osteoarticular disorders that responded to targeted treatment, leading to overall symptomatic improvement. Materials and Methods. The first patient, a 27-year-old woman diagnosed with FM two years earlier (according to the 2016 ACR/EULAR criteria: WPI 9, SSS 11) and with concomitant endometriosis and spasmophilia, complained of mixed low back pain poorly responsive to conservative therapy (amitriptyline, NSAIDs, neurotrophic supplements) and rehabilitation. Lumbosacral MRI revealed a left-sided L5 hemisacralization with hypertrophic transverse process articulating with the sacral ala (Castellvi type IIa), associated with subchondral bone marrow edema—findings consistent with Bertolotti’s syndrome (a lumbosacral transitional anomaly causing chronic low back pain). Intravenous neridronate treatment was initiated (100 mg per infusion, 4 infusions over 12 days). The second patient, a 73-year-old woman with a five-year history of FM (2016 ACR/EULAR criteria: WPI 8, SSS 10) under duloxetine therapy, presented with right hip pain initially attributed to myofascial iliopsoas syndrome in an osteoarthritic context. After failure of local infiltrative therapy, MRI demonstrated early avascular necrosis of the femoral head with subchondral bone edema. Combined treatment was started with intravenous neridronate and hyperbaric oxygen therapy (28 consecutive daily sessions). Results. In the first patient, pain intensity decreased from 8 to 4 on the VAS scale, with reduced need for NSAIDs and overall improvement in diffuse pain symptoms. In the second patient, VAS pain decreased from 8 to 5, with reduction in nocturnal pain, hyperalgesia, and allodynia, and partial resolution of bone marrow edema. A second combined treatment cycle was planned. Conclusions. These cases highlight the importance of a complete differential assessment in fibromyalgia patients presenting with refractory localized pain. The identification of coexisting structural conditions, as in the cases reported, can provide specific therapeutic targets, contributing to symptomatic improvement and better control of central sensitization. An integrated clinical approach—combining fibromyalgia diagnosis with the detection of concomitant somatic pathologies—represents a key strategy to optimize outcomes in patients with complex chronic pain.