Spinal Mass Research Articles

Relationships Between Spinal Alignment and Muscle Mass in Osteoporosis Patients Over 75 Years of Age Who Were Independent and Maintained Their Activities of Daily Living.

IntroductionElderly patients with osteoporosis often complain of back pain associated with pathological vertebral fractures caused by abnormal spinal alignment. Few reports evaluate the relationships among muscle mass, bone mineral density (BMD), sagittal spinal alignment, and low back pain. We hypothesized that decreasing muscle mass in elderly patients with osteoporosis could cause spinal alignment abnormalities. The aim of the current study were to compare the characteristics between spinal sagittal normal alignment and malalignment and to evaluate the relationships between sagittal spinal alignment and muscle mass in elderly patients with osteoporosis.MethodsFifty patients aged 75 years or more (mean age = 80.5 years) with osteoporosis were included in this study. We evaluated the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), the number of vertebral fractures (N of VFs), BMD by dual-energy X-ray absorptiometry, and trunk and skeletal muscle mass using bioelectrical impedance. Low back pain was evaluated using the Oswestry Disability Index (ODI). Corrected trunk muscle mass (trunk muscle mass index, TMI) and corrected limb muscle mass (skeletal mass index, SMI) also were measured. Patients were divided into two groups for comparison: a ‘normal’ group and a sagittal spinal ‘malalignment’ group. Multiple regression analysis was carried out to evaluate the relationship between spinal sagittal parameters and muscle mass.ResultsComparisons between normal and malalignment groups for SVA, N of VFs, BMI, and SMI showed significantly higher in the malalignment group versus the normal group (p < 0.05). N of VFs, BMI, and TMI, for PT, and BMI, TMI, SMI, and ODI scores for PI-LL showed significantly higher in the malalignment group versus the normal group (p < 0.05). There were significantly more vertebral fractures in the malalignment group than in the normal group (p < 0.05). However, there were no significant differences of pure muscle mass between the two groups. When adjusted by BMD and the number of vertebral fractures, SMI and TMI were positively correlated to PI-LL and SVA (p < 0.05).ConclusionElderly patients with osteoporosis and a sagittal spinal malalignment had more vertebral fractures and a higher risk of low back pain than patients with normal spinal alignment. Patients with a sagittal spinal malalignment who were independent and maintained their activities of daily living (ADL) showed high BMI and maintained muscle mass, independent of BMD and the N of VFs, contrary to our hypothesis.

Diagnosis, treatment and etiology analysis of nerve compression by bone fragment after lumbar spine surgery

To explore the diagnosis, treatment, cause and prevention of nerve compression by bone fragment after lumbar spine surgery. The clinical data of 23 patients with nerve compression by bone fragment after lumbar spine surgery from February 2012 to March 2019 were collected retrospectively, including 9 males and 14 females, aged 42 to 81 years with an average of (62.60±5.70) years. The surgical methods included lumbar interbody fusion in 20 cases and spinal endoscopy in 3 cases. All 23 patients experienced radiating pain on the decompression side or the contralateral limb after operation. The time of occurrence was from immediately after operation to 2 weeks after operation, with an average of (3.2±1.7) days. All patients underwent postoperative examination of lumbar spine CT or MRI to confirm residual ectopic bone fragments, and at the same time, bilateral lower extremity color Doppler ultrasound excluded thrombosis. Sources of ectopic bone fragments:14 cases of residual bone fragments caused by intervertebral fusion bone graft loss or fenestration fusion, 6 cases of fractured upper articular process head, and 3 cases of upper articular process bone remaining during spinal endoscopic surgery. The patient's hospital stay was 10 to 37 (23.4±6.2) days. All patients were followed up for 6 to 25 (13.6±3.4) months. Three patients underwent posterior open nerve root exploration for removing bone fragments on the same day or the second day after surgery, and the symptoms were relieved. Twenty patients underwent conservative treatment firstly, and 13 patients were discharged after pain relieved by conservative treatment, 7 patients failed conservative treatment, the 2 cases of failed 7 cases had undergone nerve root block surgery during conservative treatment. Two patients underwent spinal endoscopy nerve root exploration and bone mass removal, and five patients underwent posterior open nerve root exploration and bone fragmentation removal. All postoperative pain symptoms were relieved. Preoperative CT, MRI and intraoperative bone fragment removal confirmed the shape and location of the bone fragments. The most likely source of bone fragments was the loss of intervertebral fusion bone grafts or residual bone fragments resulting from fenestration fusion (14 cases), fractured upper articular process head (6 cases), and upper articular process bones remaining in endoscopic surgery (3 cases). According to the Macnab criteria in evaluating clinical outcome, 20 cases got excellent results and 3 good. After the lumbar spine surgery, the nerve compression by bone fragments is treated with appropriate treatments, and good clinical results can be obtained. Timely removal of residual bone fragments during operation and careful exploration of nerve roots before closing incision can avoid such complications.

Spinal Syrinx Due to Lipiodol-Induced Arachnoiditis

We present a case of a progressive symptomatic intramedullary cyst, diagnosed decades after Lipiodol injection. Lipiodol was originally administered intrathecally for the radiologic diagnosis of spinal masses. A link between the lesion and the history of Lipiodol injection was never suspected. Surgical exploration revealed a membrane above the lesion, separating the intradural space in a cranial and caudal compartment. On the level of the cyst, we identified glassy pearls containing a fatty liquid, compatible with Lipiodol deposits. We hypothesize that the syrinx is secondary to the impact of cerebrospinal fluid pulsations on the reactive membrane and that this membrane originated from an arachnoiditis caused by Lipiodol deposits. Lipiodol was indeed abandoned after it was found to cause arachnoiditis and neurologic sequelae. Despite the cessation of its usage, the causal role of Lipiodol in arachnoiditis and spinal cyst formation should still be considered, as symptoms may arise many years after Lipiodol administration.

Fluoroscopic landmarks and trajectories for safe posterior percutaneous transarticular C1-C2 screw insertion: a CT-based simulation study.

To determine the safe screw trajectory for posterior transarticular fixation of C1-C2 without direct visualisation of C2 lateral masses and by using fluoroscopic landmarks only. Fluoroscopic models of the craniovertebral region in frontal and sagittal planes were reconstructed using 1-mm interval computed tomography scans of the cervical spine in 30 patients. The imitation model of the screw trajectory was then applied with verification of the exact screw localisation using multiplanar reconstruction. Twenty-seven trajectories for 60 oblique C1-C2 reformations were tested. In the frontal plane, all correct trajectories passed through the medial waistline point (WstP) of C3 and through the middle of the lateral mass of C1. In the lateral plane, the posterior spinal process-lateral mass (SpLM) point-middle C1 anterior tuberculum point (ATP), middle SpLM-upper ATP, and lower SpLM-odontoid point (ODP)-had relatively low rates of vertebral artery (VA) injury (2.3%, 4.6%, and 7%, respectively) and other screw malpositions (6.9%, 4.6%, and 4.6%, respectively). In cases of an isthmus height exceeding 8mm, there were no incidences of VA injury. Patients with an isthmus width greater than 7mm had a lower risk of screw malposition. We identified potentially safe trajectories for percutaneous posterior transarticular fixation of C1-C2. Using SpLM, ATP, and ODP landmarks in the lateral plane, and WstP and C1 middle landmarks in the frontal plane, it is possible to achieve an acceptable screw position without direct visualisation of the C2 lateral mass.

An atypical presentation of metastatic Ewing sarcoma to the spine

Ewing sarcoma (ES) is a rare malignancy of the young, primarily arising from the bones. Uncommonly, it can arise extraskeletally and, among the rarest cases, from the spinal extradural tissues. The patient is a previously well 26-year-old male who presented with radicular low back pain. Magnetic resonance imaging revealed an L5-S1 spinal canal mass with possible metastases to the vertebral and pelvic bones. The initial diagnosis was challenging, with differentials of an intradural tumor, infection, solid organ tumor metastasis, and lymphoma. The patient subsequently underwent decompression and debulking of his spinal tumor, which was found to be extradural. Histological and pathological studies supported the diagnosis of metastatic ES. This case report highlights an atypical presentation of ES. Although exceedingly rare, young patients can still present with metastatic spinal disease. Clinicians should always consider more sinister diagnoses and investigate further, especially if red flag symptoms are present.

Central nervous system manifestations of hematological malignancies

Objective: Hematological malignancy presenting primarily with central nervous system (CNS) manifestations is rare and often portends a worse prognosis. The aim of this study is to report the spectrum of hematological malignancies presenting primarily with CNS symptoms. Materials and Methods: All histologically verified hematological malignancies involving CNS from January 2016 to December 2018 were included. The presence of lymphadenopathy, organomegaly, and bone marrow (BM) examination results was recorded to rule out a spread from systemic disease. The diagnosis was aided by special stains (reticulin) and immunohistochemistry (IHC) as appropriate. Antibodies used were CD20, CD3, CD10, Bcl 2, Bcl 6, MUM 1, CD138, CD68, MPO, PCK, and Ki67. The Hans algorithm was used to classify diffuse large B cell lymphoma (DLBCL) into germinal center B-cell (GCB) and non-GCB types. Results: During the study period, 18 DLBCLs, 4 plasmacytomas, and 3 myeloid sarcomas (MSs) were diagnosed. DLBCLs included 16 primary central nervous system lymphomas (PCNSLs) and 2 systemic lymphomas with evidence of lymphadenopathy. PCNSLs had male predominance and a mean of 46 (14–67) years. Frontal lobe was the most common location. Seven (70%) PCNSLs were non-GCB type and 3 (30%) were GCB type. One was a primary spinal T cell/histiocyte-rich large B cell lymphoma (a variant of DLBCL). Two were diagnosed as corticoid-mitigated lymphoma. One of the three MS cases had acute myeloid leukemia on BM examination and the rest two were isolated spinal masses with normal BM study. There were four spinal plasmacytomas, presenting with cord compression. Conclusion: Primary CNS presentation of hematological malignancies requires a high index of suspicion clinically and radiologically, and diagnosis requires IHC for proper classification.

Thalidomide Use for Complicated Central Nervous System Tuberculosis in Children: Insights From an Observational Cohort.

Much of the neurological sequelae of central nervous system (CNS) tuberculosis (TB) is due to an excessive cytokine-driven host-inflammatory response. Adjunctive corticosteroids, which reduce cytokine production and thus dampen the inflammation, improve overall survival but do not prevent morbidity. This has prompted investigation of more targeted immunomodulatory agents, including thalidomide. We describe a retrospective cohort of 38 children consecutively treated with adjunctive thalidomide for CNS TB-related complications over a 10-year period. The most common presenting symptom was focal motor deficit (n = 16), followed by cranial nerve palsies and cerebellar dysfunction. Three of the 38 children presented with large dural-based lesions, manifesting as epilepsia partialis continua (EPC), 4 presented with blindness secondary to optochiasmatic arachnoiditis, and 2 children developed paraplegia due to spinal cord TB mass lesions. Duration of adjunctive thalidomide therapy (3-5 mg/kg/day) varied according to complication type. In children compromised by TB mass lesions, the median treatment duration was 3.9 months (interquartile range [IQR], 2.0-5.0 months), whereas in children with optic neuritis it was 2.0 months (IQR, 1.3-7.3 months) and in EPC it was 1.0 months (IQR, 1-2.5 months). Satisfactory clinical and radiological response was observed in 37 of the children. None of the children experienced rashes, hepatitis, or hematologic derangements or complained of leg cramps. This study is the largest cohort of adult or pediatric patients treated with adjunctive thalidomide for CNS TB-related complications. The drug has proved to be safe and well tolerated and appears to be clinically efficacious. The potential role of thalidomide or analogues in the treatment of other tuberculous meningitis-related complications requires further exploration.

RARE-30. A RARE CASE OF PRIMARY EWING’S SARCOMA OF THE CERVICAL SPINE

Ewing sarcoma family of tumors predominantly affect the pediatric population in the long bones of the extremities or the pelvis, and only 8% of cases arise within the spine. Primary Ewing’s sarcoma of the cervical spine is extremely rare and less than 30 cases have been reported in the literature thus far. Here we present a case of primary Ewing’s sarcoma of the cervical spine in a 28-year-old female who presented with a three-month history of neck pain and right arm radiculopathy. MRI revealed a homogeneously contrast enhancing, eccentric mass with dural tail at C2-C7. After undergoing a hemilaminectomy, histopathology confirmed extraosseous Ewing’s sarcoma with CD99 positivity. A comprehensive systemic and neuraxis work-up ruled out overt metastasis. We extrapolated data from children’s cooperative group studies and IESS-II clinical trial to formulate a three phase treatment protocol as described below. To date, patient is in remission with no evidence of any residual disease in the cervical spine. In conclusion, although Primary Ewing’s sarcoma of the cervical spine is extremely rare it should be considered a differential diagnosis in patients with neck pain and a spinal mass under the age of thirty. Less than 25% of EFT’s present with overt metastasis and almost all have subclinical metastatic disease at the time of diagnosis, therefore, a comprehensive evaluation and systemic chemotherapy is recommended. We recommend a multidisciplinary approach of surgical decompression to preserve neurological functions, followed by compressed chemotherapy regimens, reevaluation for local treatment, and adjuvant chemotherapy.

PATH-44. AN UNUSUAL PRESENTATION OF A PEDIATRIC MIDLINE H3K27M-MUTANT TUMOR WITH DISSEMINATED CRANIOSPINAL LEPTOMENINGEAL DISEASE

Abstract BACKGROUND H3K27M-mutant midline lesions were recently reclassified by the WHO as “Diffuse Midline Glioma” (DMG) based on their molecular signature. DMG is one of the most common and most lethal pediatric brain tumors; terminal progression is typically caused by local progression or secondary leptomeningeal dissemination. H3K27M mutations have also been infrequently associated with a histologically diverse set of lesions, particularly spinal masses with early leptomeningeal spread, but the role of H3K27M in these atypical lesions remains poorly understood. CASE PRESENTATION A 15-year-old girl was found to have a T2/FLAIR-hyperintense and heterogeneously contrast-enhancing thalamic mass accompanied by severe leptomeningeal enhancement along the entire neuraxis. Initial infectious workup was negative, and open intracranial biopsy was inconclusive. Follow-up spinal arachnoid biopsy was diagnostic for H3K27M neuroepithelial tumor, thereafter classified as DMG. Biopsy also showed focal p53 immunopositivity, variable immunoreactivity for GFAP and synaptophysin, and an increased proliferation index, altogether suggestive of a glioneuronal origin. She received craniospinal irradiation (CSI) to 41.4Gy with a boost to the thalamic lesion to 54Gy. Imaging 1-month post-radiation demonstrated significant treatment response only with residual enhancement at the conus. CONCLUSIONS This case report describes the unique presentation of an H3K27M-mutant midline lesion with significant craniospinal leptomeningeal spread on admission and atypical glioneuronal histopathological markers. Given her avid leptomeningeal disease, spinal dural biopsy could have been considered earlier given its diagnostic yield in classifying the lesion as DMG. This lesion, however, additionally demonstrated synaptophysin positivity. Per extensive literature review, this histopathology is also potentially consistent with diffuse leptomeningeal glioneuronal tumor (DLGNT). This patient’s uniquely marked treatment response to CSI is also not typically observed in DMG, further supporting the possibility of an alternative molecular identity. In atypical DMG cases, particularly with early leptomeningeal spread, additional consideration of clinical and histopathological context is warranted for accurate diagnosis and prognostication.

Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature.

Meningiomas of the spinal canal comprise up to 40% of all spinal tumors. The standard management of these tumors is gross total resection. The outcome and extent of resection depends on location, size, patient's neurologic status, and experience of the surgeon. Heavily calcified spinal meningiomas often pose a challenge for achieving gross total resection without cord injury. To report our experience with the BoneScalpel Micro-shaver to resect heavily calcified areas of spinal meningiomas adherent to the spinal cord without significant cord manipulation, achieving gross total resection and outstanding clinical results. Seventy-nine and 82-yr-old females presented with progressive leg weakness, paresthesias, and gait instability. Magnetic resonance imaging of the thoracic spine showed a homogenous enhancing intradural extramedullary mass with mass effect on the spinal cord. Midline bilateral laminectomy was performed, and the dura was open in midline. The lateral portion of the tumor away from the spinal cord was resected with Cavitron Ultrasonic Surgical Aspirator while the BoneScalpel Micro-shaver (power level 5 and 30% irrigation) was brought into the field for the calcified portion of the tumor adherent to the spinal cord. Gross total resection was achieved for both cases. At the 2-wk postoperative visit, both patients reported complete recovery of their leg weakness with significant improvement in paresthesias and ataxia. The ultrasonic osteotome equipped with a microhook tip appears to be a safe surgical instrument allowing for effective resection of spinal meningiomas or other heavily calcified spinal masses not easily removed by usual surgical instrumentation.

Neurosurgical and neuro-immunological management of IgG4-related hypertrophic sclerosing pachymeningitis. A literature survey and discussion of a unique index case

BackgroundDural thickening is observed in lymphoma, dural carcinomatosis, meningioma, tuberculosis, and autoimmune diseases. We encountered a patient with dural thickening and complaints of neck and back pain, numbness and loss of strength in the hands. The patient also suffered from polychondritis and had previously received steroid and methotrexate treatment for this indication. The patients’ serum was also positive for ANA, yet she did not have any other findings suggesting lupus. Our radiological and pathological analysis revealed IHSP (IgG4-related hypertrophic sclerosing pachymeningitis). In this review study, we provided a detailed literature survey to increase the awareness about IHSP in the neurosurgical community. MethodsMRI (magnetic resonance imaging)-based radiological analyses revealed a posterior extramedullary spinal mass extending from C2 to T2-T3 level. The dural mass was surgically excised and a broad panel of immunohistochemical markers including S100, EMA, CD246/ALK-1, CD45, CD20, CD79a, CD138, CD68, CD1a and CD34 was studied. Immunoglobulin heavy chain/kappa chain gene rearrangement analysis was performed which ruled out a lymphoproliferative disorder. ResultsMRI and pathological findings suggested IHSP. As the disease relapsed with a new anterior extramedullary multilobulated lesion extending from C5 to T1 level, the patient is now closely monitored for further medical and surgical treatment. ConclusionsIHSP is a relatively novel entity of hypertrophic pachymeningitis and should be included in the differential diagnosis of dural thickening. The fibrosis accompanying IHSP may not respond to medical treatment, which includes steroids and immunosuppressive agents. Additionally, neurological deficits, seizures, spinal decompression, hydrocephalus, or brainstem compression necessitate early surgical intervention. A continued vigilance is also necessary as the disease may relapse long-term following surgical treatment.

Diffuse Leptomeningeal Glioneuronal Tumor of Childhood.

Diffuse leptomeningeal glioneuronal tumor is a newly defined entity under the neuronal and mixed neuronal-glial tumors category in the 2016 World Health Organization classification of brain tumors. In this series, we report clinical, radiologic, and histologic findings in 7 cases of diffuse leptomeningeal glioneuronal tumor. Our cases and literature review indicate that the most characteristic imaging finding is diffuse intracranial and intraspinal nodular leptomeningeal thickening and enhancement. This is often associated with small cyst-like, nonenhancing lesions. It should be noted that tumors sometimes bear nontypical features, for example, presenting as a solitary spinal cord mass without leptomeningeal involvement or with a dominant intracranial mass. In children with characteristic imaging findings and without clinical features of infection, the radiologist has an opportunity to promptly raise the possibility of diffuse leptomeningeal glioneuronal tumor, and thereby, affect streamlined diagnostic evaluation.

A case of recurring spinal ependymoma in 37-years old man after surgery and adjuvant therapy

We present the case of a 39-years old man who underwent three surgeries because of spinal ependymoma located in cauda equina region. He presented at the Oncology Institute of Vojvodina for combined adjuvant chemo- and radiotherapy after the second surgery. An MRI examination performed after six cycles of therapy showed no signs of disease. 26 months later, a follow-up MRI showed recurrence of disease in the form of small drop metastasis. Six months later, the patient underwent the third surgery. The patient is currently receiving another cycle of radiotherapy, and is scheduled for additional cycles of chemotherapy. Ependymomas are the most common spinal cord malignancy in adults. The symptoms are nonspecific which often causes a delay in diagnosis. An MRI examination of the spine with contrast admission is the study of choice for detecting spinal cord masses. Surgery is the first-line therapy for ependymomas. Recurrence rate is associated with the extent of surgical resection, with en bloc and gross-total resection being associated with lower rates of disease recurrence. In children under 3 years, adjuvant chemotherapy is advocated, while older children and adults undergo adjuvant radiotherapy or combined chemo- and radiotherapy in cases of subtotal resection or tumor recurrence.

Transforaminal Endoscopic Approach for Large-Sample Tumor Biopsy using Beveled Working Channel for Core Technique: A Technical Note

Identifying the histopathological diagnosis of a spinal tumor is the necessary step prior to pursuing subsequent treatment. Both minimally invasive and open spinal procedures have been described as useful methods of obtaining tumor tissue for diagnosis but differ by their limitations. Minimally invasive techniques, such as computed tomography-guided biopsies, can expose the patient to radiation, and the tissue obtained may be nondiagnostic. Tubular and open procedures require collateral soft-tissue damage and may require bony removal leading to iatrogenic injury. Endoscopic approaches to the spine can be employed to avoid treatment delay in diagnosis, decrease length of stay, and provide adequate tissue for diagnosis. We describe the surgical planning, tumor localization, and transforaminal endoscopic approach for tissue diagnosis of a lumbar spinal mass in a patient with a known history of Hodgkin lymphoma and non-Hodgkin lymphoma after a nondiagnostic computed tomography- guided biopsy. Final histopathological diagnosis of the lumbar spinal mass was consistent with large B-cell non-Hodgkin lymphoma. We demonstrate the application of an endoscopic transforaminal approach in spine oncology. We also describe our technique on how we use a beveled working channel to obtain a large tissue core sample for definitive diagnosis.

Surgical treatment of cervical spine fractures in ankylosing spondylitis patients: posterior stabilization using intraoperative CT scanner-based navigation.

The authors analyzed aseries of ankylosing spondylitis patients with cervical spine fracture undergoing posterior stabilization using spinal navigation based on intraoperative CT imaging. The purpose of this study was to evaluate the accuracy and safety of navigated posterior stabilization and to analyze the adequacy of this method for treatment of fractures in ankylosed cervical spine. Prospectively collected clinical data, together with radiological documentation of aseries of 8 consecutive patients with 9 cervical spine fracture were included in the analysis. The evaluation of screw insertion accuracy based on postoperative CT imaging, description of instrumentation-related complications and evaluation of morphological and clinical results were the subjects of interest. Of the 66 implants inserted in all cervical levels and in upper thoracic spine, only 3 screws (4.5%) did not meet the criteria of anatomically correct insertion. Neither screw malposition nor any other intraoperative events were complicated by any neural, vascular or visceral injury. Thus we did not find areason to change implant position intraoperatively or during the postoperative period. The quality of intraoperative CT imaging in our group of patients was sufficient for reliable trajectory planning and implant insertion in all segments, irrespective of the habitus, positioning method and comorbidities. In addition to stabilization of the fracture, the posterior approach also allows reducing preoperative kyphotic position of the cervical spine. In all patients, we achieved astable situation with complete bone fusion of the anterior part of the spinal column and lateral masses at one year follow-up. Spinal navigation based on intraoperative CT imaging has proven to be areliable and safe method of stabilizing cervical spine with ankylosing spondylitis. The strategy of posterior stabilization seems to be asuitable method providing high primary stability and the conditions for asubsequent high fusion rate.

Assessment of serum vitamin D levels in surgical adolescent idiopathic scoliosis patients

BackgroundThe mechanism behind idiopathic scoliosis and its progression is not fully understood. Vitamin D insufficiency is known to play a role in the progression and/or occurrence of a variety of bone diseases. In this study, we aimed to estimate the prevalence of vitamin D insufficiency among patients with adolescent idiopathic scoliosis. Additionally, we aimed to calculate the differences in serum vitamin D levels, Cobb angles, spinal bone mass densities, and serum alkaline phosphatase levels between the sexes in the sample and to assess the possibility of a correlation between any of these factors.MethodsDemographic details, vitamin D levels, Cobb angle, spinal bone mass density, and alkaline phosphatase were collected from the records of 67 patients who were eligible for corrective surgery. These values were compared to normal levels and between the sexes within the study.ResultsOf the 67 patients, 54 (80.6%) were female. The mean serum vitamin D level was 37.86 ± 26 nmol/L, and levels below normal were found in 92.5% of the patients. Statistical analysis showed significant differences (p = 0.002) in serum alkaline phosphatase levels between the sexes. No correlation was found between vitamin D levels and the Cobb angles, spinal and bilateral femoral neck bone mass densities, and serum alkaline phosphatase levels.ConclusionsMost adolescent idiopathic scoliosis patients had insufficient serum vitamin D levels and also suffered from low bone mineral density at an early age.

MON-365 Novel Use of Abaloparatide to Augment Spinal Fusion in Patient Undergoing Cervicothoracic Revision Surgery

Objective To present a case of using Abaloparatide (PTHrP 1–34 analogue) to promote spinal fusion in a patient with history of cervical instability s/p multiple cervical operations with non-union. Case Presentation 66 year-old female with a history of multiple sclerosis, obesity and hypothyroidism underwent neurosurgical evaluation of neck pain. She was found to have cervical spinal stenosis causing neck pain, radiculopathy, motor deficits and ataxia. Initially underwent anterior cervical discectomy and fusion which temporarily alleviated symptoms before suffering nonunion. Subsequently underwent two additional surgeries which also eventually failed. She presented to our facility for revision corpectomy and spinal fusion. Given her history of nonunion, endocrinology was consulted for evaluation of metabolic bone disease. No known personal or family history of metabolic bones disease. No history of chronic steroid use. Initial endocrine evaluation excluded common pathologies. A decision was made to pursue anabolic osteoporosis therapy to attempt to augment the spinal fusion process. Patient started on Abaloparatide 80mcg daily 2 weeks post procedure with planned 12-week therapy course. Cervical CT at 3 and 6 months showed post-surgical cervicothoracic fusion with no signs of non-union. Discussion Abaloparatide is a 34 amino acid synthetic analogue of parathyroid hormone related peptide (PTHrP) which works by selectively activating PTH1 receptor found on osteoblasts. Currently anabolic therapies are only FDA approved for treatment of osteoporosis but there is reported off label use in cases of spinal fusions, arthroplasty and fracture healing. Studies have shown that presence of PTH and PTHrP are necessary for fracture healing. Animal studies have also shown that intermittent PTH promotes spinal fusion. This case represents a novel use for Abaloparatide to augment spinal fusion in a human clinical model. Conclusion Further studies are warranted to better understand mechanism of action, drug timing and duration for optimal treatment of anabolic therapies in bone fractures and healing. The use of anabolic therapies like Abaloparatide can be considered in patients undergoing spinal fusion surgery at high risk for non-union or undergoing revision for failed fusion.ReferencesO’Loughlin PF, Cunningham ME, Bukata SV et al. Parathyroid Hormone Augments spinal fusion, fusion mass, and fusion mass quality in a rabbit spinal fusion model. Spine 2009 January; 34: 121–130

The Central Dot Sign : ASpecific Post-gadolinium Enhancement Feature of Intramedullary Spinal Cord Metastases.

Peripheral enhancement characteristics on magnetic resonance imaging (MRI), namely the rim and flame signs, are specific for intramedullary spinal cord metastases (ISCM) compared to primary cord masses. The study compared the frequency of anovel finding-the central dot sign-in ISCMs versus primary intramedullary masses. In this study 45 patients with 64ISCMs and 64control patients with 64primary intramedullary cord masses were investigated and 2 radiologists blinded to lesion type independently evaluated MR images for the presence of acentral dot sign: apunctate focus of enhancement in/near the center of an enhancing intramedullary mass. The frequency of this sign in the two patient groups was compared. A total of 63 enhancing ISCMs in 44patients and 54enhancing primary cord masses in 54patients were included. The central dot sign was identified in 6% (4/63) of enhancing ISCMs in 9% (4/44) of patients and in none (0/54) of the enhancing primary cord masses (p = 0.038, per patient). The specificity for diagnosing ISCMs among spinal cord masses was 100%. The central dot sign was present in the axial plane only in two ISCMs and in the axial and sagittal planes in two ISCMs. The two ISCMs harboring the central dot sign also demonstrated both the previously described rim and flame signs, and two also demonstrated the rim sign alone. The central dot sign is not sensitive but highly specific for ISCMs compared to primary spinal cord masses. The rim and/or flame signs may or may not be concurrently present in ISCMs.

Abstract #806418: Follicular Thyroid Carcinoma Presenting as a Lumbar Spinal Mass

Abstract #806418: Follicular Thyroid Carcinoma Presenting as a Lumbar Spinal Mass

Titanium Mesh in Spinal Fusion: A Case Serie

Background: Maxillofacial titanium mesh is most commonly used in reconstructive surgery for its versatility, stability, affordability, tissue tolerance, and compatibility with multiple imaging modalities. Here we describe the novel use of maxillofacial titanium mesh for spinal fusion surgery in a case series. Methods: We present three cases requiring instrumented spinal fusion. A 95-year-old women with one-month history of falls and back pain was found to have a spinal canal mass at T2-T3 and T11 burst fracture. A 32-year-old male had a L4 burst fracture following a motor vehicle accident. A 66-year-old female with one-year history of lumbar pain was diagnosed with thoracolumbar kyphosis, secondary hyperlordosis of the lumbar spine, stenosis at L4-L5, and L2-L5 spondylolisthesis. Results: Instrumented spinal fusion was carried out and maxillofacial titanium mesh was cut and contoured appropriately prior to being precisely placed over the dura mater. Post-operative imaging demonstrated adequate fixation for all cases. No intraoperative or postoperative complications occurred. Conclusions: Maxillofacial titanium mesh has long been used in maxillofacial reconstructive surgery for a variety of reasons including malleability, strength, and the distinct biocompatibility of titanium. However, titanium mesh may also be used to augment spinal fusion for tumor, trauma, and degenerative conditions without complication. Titanium mesh can offer the spine surgeon a safe, cost-effective and efficacious tool when used in spinal fusion. Future randomized controlled trials are needed to validate these findings in large sample sizes. Level of Evidence: 4.