Spinal Pathology Research Articles

Association of MRI findings with paraspinal muscles fat infiltration at lower lumbar levels in patients with chronic low back pain: a multicenter prospective study

ObjectiveIn chronic low back pain (CLBP), the relationship between spinal pathologies and paraspinal muscles fat infiltration remains unclear. This study aims to evaluate the relationship between MRI findings and paraspinal muscles morphology and fat infiltration in CLBP patients by quantitative MRI.MethodsAll the CLBP patients were enrolled from July 2021 to December 2022 in four medical institutions. The cross-sectional area (CSA) and proton density fat fraction (PDFF) of the multifidus (MF) and erector spinae (ES) muscles at the central level of the L4/5 and L5/S1 intervertebral discs were measured. MRI findings included degenerative lumbar spondylolisthesis (DLS), intervertebral disc degeneration (IVDD), facet arthrosis, disc bulge or herniation, and disease duration. The relationship between MRI findings and the paraspinal muscles PDFF and CSA in CLBP patients was analyzed.ResultsA total of 493 CLBP patients were included in the study (198 females, 295 males), with an average age of 45.68 ± 12.91 years. Our research indicates that the number of MRI findings are correlated with the paraspinal muscles PDFF at the L4/5 level, but is not significant. Moreover, the grading of IVDD is the primary factor influencing the paraspinal muscles PDFF at the L4-S1 level (BES at L4/5=1.845, P < 0.05); DLS was a significant factor affecting the PDFF of MF at the L4/5 level (B = 4.774, P < 0.05). After including age, gender, and Body Mass Index (BMI) as control variables in the multivariable regression analysis, age has a significant positive impact on the paraspinal muscles PDFF at the L4-S1 level, with the largest AUC for ES PDFF at the L4/5 level (AUC = 0.646, cut-off value = 47.5), while males have lower PDFF compared to females. BMI has a positive impact on the ES PDFF only at the L4/5 level (AUC = 0.559, cut-off value = 24.535).ConclusionThe degree of paraspinal muscles fat infiltration in CLBP patients is related to the cumulative or synergistic effects of multiple factors, especially at the L4/L5 level. Although age and BMI are important factors affecting the degree of paraspinal muscles PDFF in CLBP patients, their diagnostic efficacy is moderate.

SPINAL INTRADURAL EXTRAMEDULLARY TUMORS AND SIMILAR PATHOLOGIES: A SINGLE CENTER STUDY

Background: We wanted to analyze the neurological symptoms and prognosis of five spinal IDEM (intradural extramedullary) tumors cases diagnosed, and to emphasize that a spinal cord tumor can be found incidentally in evoluation of the proximal regions of the vertebral column in patients who were mistakenly operated for lumbar disc herniation on lumbar MRI, but whosesymptoms did not resolve. Objective: To emphasize the need for examinations such as MRI along the vertebral columna in patients with different spinal pathologies and whose symptoms and clinical signs do not improve. Methods: Patients with spinal IDEM tumors treated with surgical excision and followed for more than 2 years were retrospectively analyzed. Issessed pain with the visual analo scale (VAS), and neurological function with the Nurrick grade.Preoperative complaint time,location of tumor in sagital and axial sections in MRI and pathological diagnosis were investigated. Results: The pathological diagnosis in our study was meningioma in two cases,dural arteriovenous fistula in one case,teratoma in one case ,and myxopapilary epandimoma in one case.İn one case,disc herniation surgery was performed in another hospital due to misdiagnosis, but because the patient’s complaints were resistant. In examination, an IDEM tumor at T11 level was detected, and he was operated. In all cases the VAS score (mean) was reduced from 7.8 to 0.4 as well as the Nurrick grade (mean) was from 2.0 to 0.6. In the dAVF case, spasticity in the lower extremities, bladder and bowel disfunction continued. Conclusion: In cases with severe neurological deficits, MRI scanning of the proximal parts of the vertebral column will help in the differential diagnosis of the lesion occupying the intraspinal space.

Harmonization of Longitudinal Diffusion Tensor Imaging Data of the Pediatric Cervical and Thoracic Spinal Cord at 3T Using Longitudinal ComBat.

Diffusion tensor imaging (DTI) of the spinal cord has been extensively used to identify biomarkers for spinal cord pathology. Previously, the longitudinal ComBat (longComBat) technique was examined to reduce scanner effects in multi-site, multi-scanner spinal cord DTI data. This study aimed to assess its effectiveness on longitudinal scans using a single-scanner pediatric dataset, including healthy and spinal cord injury (SCI) subjects. Two identical datasets were collected from 42 healthy and 27 SCI subjects with a 2-hour interval between scans on a 3T Siemens MRI scanner. Axial DTI images of the entire cervical and thoracic spinal cord were obtained, and various average diffusion tensor metrics (FA, MD, RD, & AD) were measured at each vertebral level. Pearson correlation and intraclass correlation coefficients were used to evaluate inter- and intra-subject agreement pre- and post-harmonization. Minimal improvement in agreement was observed with the mean square residual (MSR) model, while the restricted maximum likelihood estimator (REML) model showed reduced intra-subject agreement in all the tensor metrics. The significant variability between longitudinal DTI scans within a single scanner was likely due to physiological motion rather than scanner effects. Post-harmonization using the longComBat MSR model showed limited improvement in agreement.

Can Frailty Predict 90-Day Postoperative Outcome in Elderly Patients with Degenerative Cervical Spine Pathology?

Abstract Background: Age and general health status are major points of concern in the decision-making process when it comes to cervical spine surgeries in the elderly. While there have been studies on the various frailty indices in their ability to predict outcomes in spine surgery, there have been few articles that have investigated the utility of the 5-point modified Frailty Index (mFI-5) for this purpose. Our study attempts to have a granular view of the problem of frailty in the elderly and study the correlation between the mFI-5 and American society of anesthesiologists (ASA) classes, and the 90-day surgical outcome of patients of 60 years and above, operated for degenerative cervical spine pathologies. Materials and Methods: This is a single-center retrospective study of prospectively collected data on 41 patients aged 60 years and above who were operated at our institute between January 1, 2017, and December 31, 2022. We studied the correlation of mFI-5, ASA class and the Spinal Surgical Invasiveness Index (SII) with various outcome variables like length of hospital stay, need for ICU stay, complications, severe adverse events (Clavien Dindo grade 4 and above), re-intubation, unplanned re-admission, and need for re-operation. Results: Statistical analysis showed a significant correlation between ASA class and mFI-5 scores (Chi square test, P value: 0.0401) and between ASA scores and the need for an ICU stay (Chi square test, P value: 0.0047). SII was found to correlate with length of hospital stay (Spearman rank test, P value: 0.0037) and with need for ICU care (Mann–Whitney U test, P value 0.0422). However, there was no significant correlation between the mFI-5 scores and the outcome variables. Conclusion: Although there was no significant correlation between mFI-5 and the 90-day surgical outcome, variables like ASA and SII had a bearing on it. Thus, it can be stated that the outcome of cervical spine surgery in the elderly is multifactorial. While frailty should put the healthcare team on alert while dealing with such patients, it should not discourage them from offering a surgical solution when required, as efficient peri-operative management by the surgical, anesthesia, and critical care teams can lead to favorable 90-day outcomes.

Cell Therapy for Intervertebral Disc Regeneration: Progress and Hurdles in Clinical Translation

Abstract Low back pain (LBP) is a pervasive global issue causing substantial disability and significant economic burden. The primary etiological factor behind LBP is intervertebral disc (IVD) degeneration, initiated in early adolescence and potentially leading to multiple spinal pathologies. However, current treatments for discogenic LBP are mainly palliative or involve invasive surgery, lacking disease-modifying therapies. Regenerative strategies, including cell therapy, may offer promising avenues to address the underlying pathology of IVD degeneration. Preclinical studies and clinical trials have demonstrated the potential of intradiscal cell transplantation to alleviate disc degeneration and associated pain with an overall favorable safety profile. Nonetheless, clinical trials present challenges, such as varying patient inclusion criteria, lack of adequate control groups, and short follow-up periods, necessitating cautious interpretation of results. This narrative review aims to provide an overview of clinical trials published to date and discuss the progress and translational hurdles of cell-based therapies for IVD degeneration and discogenic pain.

Retrospective Case Series of Vertebral Artery Injuries Associated with Cervical Spine Trauma

BackgroundVertebral artery injuries (VAI) can occur due to cervical spine trauma. VAI can prove a serious complication and potentially compromise vascular supply to the posterior aspect of the brain. Currently, there is a paucity of evidence with regards to incidence, management, and outcomes for these patients. The purpose of this study is to investigate and elucidate the incidence of VAI associated with cervical trauma at a national tertiary referral centre for spinal pathology, their respective management, and associated outcomes. MethodsA retrospective review was conducted from 2012-2021 to identify patients with VAI secondary to cervical spine trauma. Demographic, clinical, and radiological data was collected to identify common traits in injury characteristics and management. Results1013 spine patients presented to our institution across the 10-year period. 739/1013 (72.9%) were trauma patients. 42/739 (5.7%) were imaged for suspected VAI secondary to trauma. There were 14/739 (1.9%) confirmed VAI. All patients had CT-angiography for diagnosis. Four of the confirmed VAI patients (28.6%) had additional MR-angiography imaging. Right-side was the most common side of VAI injury (7/14; 50%), followed by left (5/14; 35.7%) and bilateral (2/14; 14.3%) injuries. 8/14 (57.1%) patients were prescribed anti-thrombotic therapy. Acute mortality within 3-months was noted to be 2/14 (14.3%) and occurred at 49 days and 57 days respectively. ConclusionVAI associated with cervical spine injury is rare in occurrence. However, it can be associated with high morbidity and mortality. As such, a multi-disciplinary approach to care is integral to ensuring good outcomes in these patients.

Patterns of Spine Cases in a New Neurosurgery Centre in Southeast Nigeria

Background: The Imo State Specialist Hospital (IMSSH) commenced neurosurgical services in April 2021 and spine procedures in August 2021. The activities of the hospital with respect to surgical management of spine pathologies were audited. Aims: Our aims were to look at the pattern of spinal pathologies surgically managed in the hospital including their age and sex distribution, the pathologies and procedures performed as well as immediate post operative outcomes. Methods: The case files of all spine patients who had surgical procedures at IMSSH from August 2021 to April 2023 (21 months) were retrospectively reviewed. Results: Seventy-two spine patients had surgical procedures during the study period (an average of 3 – 4 spine procedures per month). The mean age of patients was 55.4±16.1 years with a male-to-female ratio of 7: 5. The mean age for male patients was 53.86±17.83 years while that of female patients was 57.5±13.2years. The peak age range at presentation was in the 7th (n=23, 31.9%) decade. The highest frequency of procedures was performed in the lumbar/ lumbosacral spine (56.9%), followed by cervical spine (29.1%), and thoracic/thoracolumbar spine (13.8%). Degenerative spine diseases (69.4%) accounted for the highest number of spine cases, followed by spinal trauma (20.8%) and Spinal tumours (6.9%). Mortality in the immediate post-operative period was 6.9% (n=5). Conclusion: The study showed a male preponderance for spinal surgeries among our spine patients, with most cases being of degenerative spine pathology. We hope this would be helpful in formulating policies for the growth of this new Neurosurgical Centre.

Comparative Evaluation of Neck Length, Relative Neck Length and Total Body Height in Cervical Spondylosis Affected and Non-Affected Individual

Anthropometric measurements, including neck length, relative neck length and total body height, have been proposed as potential indicators of cervical spine health, yet their association with cervical spondylosis remains relatively understudied. Objective: To compare neck length, relative neck length, and total body height between individuals affected by cervical spondylosis and a non-affected control group. Methods: This case-control study was conducted at Department of Anatomy Multan Medical and Dental College (MMDC), Multan from April 2023 to September 2023. Cases were diagnosed with cervical spondylosis and controls were selected from the same population without a history of cervical spine pathology or symptoms. The collected data were analyzed using IBM SPSS, version 27.0. Results: Gender distribution revealed females in both cases (63, 60.6%) and controls (59, 56.7%). The age of participants ranged from 25 to 75 years. The mean age for cases was 49.2 ± 12.93 years and for controls was 49.7 ± 13.19 years. The mean neck length among cases and controls was 105.2 ± 17.22 mm and 107.7 ± 20.02 mm, respectively. Regarding relative neck length, cases and controls exhibited measurements of 6.41 ± 1.07 mm and 6.42 ± 1.27 mm, respectively. Height-wise, cases measured 164.4 ± 10.27 cm, while controls measured 168.3 ± 8.53 cm. Conclusions: In conclusion, while no significant differences were observed in neck length or relative neck length between cervical spondylosis patients and controls, a notable disparity in height was noted.

Artificial Intelligence in Spinal Imaging and Patient Care: A Review of Recent Advances.

Artificial intelligence (AI) is transforming spinal imaging and patient care through automated analysis and enhanced decision-making. This review presents a clinical task-based evaluation, highlighting the specific impact of AI techniques on different aspects of spinal imaging and patient care. We first discuss how AI can potentially improve image quality through techniques like denoising or artifact reduction. We then explore how AI enables efficient quantification of anatomical measurements, spinal curvature parameters, vertebral segmentation, and disc grading. This facilitates objective, accurate interpretation and diagnosis. AI models now reliably detect key spinal pathologies, achieving expert-level performance in tasks like identifying fractures, stenosis, infections, and tumors. Beyond diagnosis, AI also assists surgical planning via synthetic computed tomography generation, augmented reality systems, and robotic guidance. Furthermore, AI image analysis combined with clinical data enables personalized predictions to guide treatment decisions, such as forecasting spine surgery outcomes. However, challenges still need to be addressed in implementing AI clinically, including model interpretability, generalizability, and data limitations. Multicenter collaboration using large, diverse datasets is critical to advance the field further. While adoption barriers persist, AI presents a transformative opportunity to revolutionize spinal imaging workflows, empowering clinicians to translate data into actionable insights for improved patient care.

Biomechanical evaluation of spinal cord decompression methods in dogs

The study is relevant due to the high incidence of spinal cord compression pathologies in dogs requiring surgical intervention, and was carried out with the aim of conducting a biomechanical assessment of spinal cord decompression methods and identifying a decompression technique that has the least destabilizing effect on the thoracolumbar spine. The studies were carried out in 2023-2024. on the basis of the Department of Veterinary Surgery of the Moscow State Academy of Veterinary Medicine and Biotechnology - MBA named after K.I. Scriabin" and the Laboratory for the Development and Testing of Medical Devices and Materials of the Federal State Budgetary Institution "National Medical Research Center for Orthopedics named after. N.N. Priorov" of the Ministry of Health of the Russian Federation. The object of the study was sectional material, namely, samples of the thoracolumbar spine of dogs of chondrodystrophic and non-chondrodystrophic breeds weighing from 3 to 10 kg at the age of 5 to 8 years (20 samples in total). The range of motion of the vertebrae and the force of destruction of the spinal motion segments were determined in the native state and after modeling decompression techniques (hemilaminectomy and mini-hemilaminectomy). During hemilaminectomy, statistically significant changes in the biomechanical characteristics of the thoracolumbar spine were noted compared to mini-hemilaminectomy: an increase in the range of motion of the vertebrae in the area of decompression; increasing the range of motion of the vertebrae in topographically adjacent segments; reduction in the force of destruction of the segment in the area of decompression (changes are more pronounced in dogs of chondrodystrophic breeds). The data obtained by the authors of the article indicate that hemilaminectomy is a more destabilizing technique compared to minihemilaminectomy, and for extrusions in the thoracolumbar spine in dogs, preference should be given to mini-hemilaminectomy.

Spinal Pathology and Muscle Morphologies with Chronic Low Back Pain and Lower Limb Amputation.

Low back pain (LBP) is highly prevalent after lower limb amputation (LLA) and contributes to substantial reductions in quality of life and function. Towards understanding pathophysiological mechanisms underlying LBP after LLA, this article compares lumbar spine pathologies and muscle morphologies between individuals with LBP, with and without LLA. We queried electronic medical records of Service members with and without LLA who sought care for LBP at military treatment facilities between January 2002 and May 2020. Two groups with cLBP, one with (n = 15) and one without unilateral transtibial LLA (n = 15), were identified and randomly chosen from a larger sample. Groups were matched by age, mass, and sex. Lumbar muscle morphology, Pfirrmann grades, Modic changes, facet arthrosis, Meyerding grades, and lordosis angle were determined from radiographs and magnetic resonance images available in the medical record. Independent t-tests compared variables between cohorts while multiple regression models determined if intramuscular fat influenced Pfirrmann grades. Chi-square determined differences in presence of spondylolysis and facet arthrosis. Lordosis angle was larger with LLA (P = 0.01). Spondylolysis was more prevalent with LLA (P = 0.008; 40%) whereas facet arthrosis was similar between cohorts (P = 0.3). Muscle area was not different between cohorts, yet intramuscular fat was greater with LLA (P ≤ 0.05). Intramuscular fat did not influence Pfirrmann grades (P > 0.15). Despite similar lumbar muscle size, those with unilateral LLA may be predisposed to progress to symptomatic spondylolisthesis and intramuscular fat. Surgical and/or rehabilitation interventions may mitigate long-term effects of diminished spinal health, decrease LBP-related disability, and improve function for individuals with LLA.

Reduced mesencephalic astrocyte-derived neurotrophic factor expression by mutant androgen receptor contributes to neurodegeneration in a model of spinal and bulbar muscular atrophy pathology.

Spinal and bulbar muscular atrophy (SBMA) is a neurodegenerative disease caused by extended CAG trinucleotide repeats in the androgen receptor (AR) gene, which encodes a ligand-dependent transcription factor. The mutant AR protein, characterized by polyglutamine expansion, is prone to misfolding and forms aggregates in both the nucleus and cytoplasm in the brain in SBMA patients. These aggregates alter protein-protein interactions and compromise transcriptional activity. In this study, we reported that in both cultured N2a cells and mouse brain, mutant AR with polyglutamine expansion causes reduced expression of mesencephalic astrocyte-derived neurotrophic factor (MANF). Overexpression of MANF ameliorated the neurotoxicity of mutant AR through the inhibition of mutant AR aggregation. Conversely, knocking down endogenous MANF in the mouse brain exacerbated neuronal damage and mutant AR aggregation. Our findings suggest that inhibition of MANF expression by mutant AR is a potential mechanism underlying neurodegeneration in SBMA.

Corpus Callosum-Mediated Interhemispheric Interactions in Cervical Spondylotic Myelopathy.

The corpus callosum is crucial for interhemispheric interactions in the motor control of limb functions. Human and animal studies suggested spinal cord pathologies may induce cortical reorganization in sensorimotor areas. We investigate participation of the corpus callosum in executions of a simple motor task in patients with cervical spondylotic myelopathy (CSM) using transcranial magnetic stimulation. Twenty patients with CSM with various MRI grades of severity of cord compression were compared with 19 normal controls. Ipsilateral silent period, contralateral silent period, central motor conduction time, and transcallosal conduction time (TCT) were determined. In both upper and lower limbs, TCTs were significantly increased for patients with CSM than normal controls ( p < 0.001 for all), without side-to-side differences. Ipsilateral silent period and contralateral silent period durations were significantly increased bilaterally for upper limbs in comparison to controls ( p < 0.01 for all), without side-to-side differences. There were no significant correlations of TCT with central motor conduction time nor severity of CSM for both upper and lower limbs ( p > 0.05 for all) bilaterally. Previous transcranial magnetic stimulation studies show increased motor cortex excitability in CSM; hence, increased TCTs observed bilaterally may be a compensatory mechanism for effective unidirectional and uniplanar execution of muscle activation in the distal limb muscles. Lack of correlation of TCTs with severity of CSM or central motor conduction time may be in keeping with a preexistent role of the corpus callosum as a predominantly inhibitory pathway for counteracting redundant movements resulting from increased motor cortex excitability occurring after spinal cord lesions.

Revision Rates After Single-Level Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: An Observational Study With 5-Year Minimum Follow-Up.

Retrospective Case-Control study. This study aimed to compare rates and risk factors for all-cause 5-year revisions for patients undergoing primary single-level cervical disc arthroplasty (CDA) versus Anterior Cervical Discectomy and Fusion (ACDF). Prospective studies have compared patient reported outcomes, adjacent segment degeneration, and long-term revisions between CDA and ACDF. Despite these high-level evidence studies, well-powered, large investigations have not been adequately reported. A nationwide database was queried for patients undergoing primary single level CDA or ACDF for degenerative cervical spine pathology. Further inclusion criteria consisted of patients having a minimum of 5-year follow-up. Patients undergoing CDA were 1:5 ratio matched to patients undergoing ACDF by age, sex, comorbidities, and overall Elixhauser comorbidity index (ECI). Objectives were to compare the rates and risk factors of all-cause 5-year revisions for those undergoing single level CDA versus ACDF. Multivariate logistic regression models computed odds ratios (OR) of revisions within 5 years. P values less than 0.001 were significant. A total of 32,953 patients underwent single level CDA (N=5,640) or ACDF (N=27,313) with 5-Year minimum follow-up. The incidence of all cause revisions within 5 years were 1.24% for CDA and 9.23% for ACDF (P<0.001). After adjustment, patients undergoing single level ACDF had significantly higher odds of all-cause revisions within 5 years (OR: 8.09; P<0.0001). Additional patient specific factors associated with revisions were a history of reported drug abuse (OR: 1.51; P<0.0001), depression (OR: 1.23; P<0.0001), cardiac arrythmias (OR: 1.21; P=0.0008), hypertension (OR: 1.20; P=0.0006), and tobacco use (OR: 1.18; P=0.0003). In this study of nearly 33,000 single level cervical spine surgeries with minimum 5-year follow-up, all-cause revision rates were significantly lower for patients undergoing CDA. Surgeons may use this data to counsel patients regarding 5-year revisions following single level CDA or ACDF. III.

Challenges with two epidural catheters for labor analgesia in a patient with lumbar adhesions: a case report

BackgroundThe efficacy of neuraxial analgesia varies with spinal canal pathology. Notably, a secondary epidural catheter has been shown to increase neuraxial labor analgesia in women with spinal lesions. Therefore, we present a case in which catheter withdrawal played a critical role in achieving effective labor analgesia in a woman with epidural adhesions after lumbar discectomy who had inadequate analgesia with two epidural catheters.Case presentationWe encountered a patient with L5 lumbar epidural adhesions who reported pain even after receiving two epidural catheters. The catheters were placed in the L1/2 and L5/S intervertebral spaces. Analgesic effects were exerted when the L5/S catheter was withdrawn by 1 cm, suggesting that the catheter tip was initially placed inside the adhesion.ConclusionsCareful consideration of catheter placement and adjustments by withdrawing the catheter are crucial in managing labor analgesia in patients with known epidural adhesions.

(083) CHRONIC VULVAR PAIN AND URINARY DISTURBANCES REVEALING A LARGE TARLOV CYST IN A 41-YEAR-OLD WOMAN: A CASE REPORT

Abstract Introduction Perineural cysts, also known as Tarlov cysts, are cerebrospinal fluid-filled nerve root cysts predominantly located at the sacral spine. While typically asymptomatic, large Tarlov cysts may elicit discomforting symptoms. Diagnostic challenges stem from limited understanding and symptom overlap with various disorders. Objective This case report explores the presentation of a 41-year-old female patient exhibiting symptoms of vulvar pain and urinary disturbances, which were ultimately attributed to a large Tarlov cyst, highlighting the complexities of diagnosis and management associated with this condition. Methods A 41-year-old female patient with a past medical history of linear scleroderma, chronic left hip pain with leg length discrepancy, and family history of endometriosis presented to her primary care physician with vulvar pain and urinary symptoms. She had burning vulvar pain, predominantly on the left side, radiating from the vulvar vestibule to the perineum, which gradually worsened over 6 months. She also had lower back pain radiating into her legs and calves, along with increased urinary frequency, urgency, retention and burning upon micturition. Patient underwent a 11-month treatment regimen following a referral to pelvic pain specialist, including being initiated on gabapentin and vaginal suppositories, which provided significant pain relief. However, over time, her vulvar pain gradually worsened, and gabapentin was replaced with pregabalin. She underwent six weeks of pelvic floor physical therapy and received a series of peripheral nerve blocks, including multiple pudendal nerve blocks, trigger point injections and hydrodissection of connective tissue around the nerves, yielding little pain relief. Due to persistent vulvar pain, the patient was referred to our clinic. Her examination revealed tenderness upon palpation over the lumbar-sacral spine and sacroiliac joint and para-spinal muscle spasm on the left side. She had provoked vestibulodynia that was predominately on the posterior aspect of the vestibule with a Q-tip test 8/10, and about 4/10 at anterior vestibule. She also continued to have tenderness in her pelvic floor muscles. Given her history and physical exam, a spinal pathology was suspected, and lumbosacral MRI was ordered. Results The lumbosacral MRI revealed a Tarlov cyst measuring 7.7 cm x 3.9 cm x 4.2 cm, extending from the L5-S1 disc level to the S3-S4 vertebral body junction. The patient was subsequently referred to a neurosurgeon who performed a twelve-hour surgery, including a dissection of the intrasacral meningeal cyst that was causing sacral nerve root compression and subsequent wrapping of the weakened right S2-S3 nerve roots. Postoperatively, the pain, although decreased, persisted due to nerve root thinning and long-term compression of the sacral nerve roots. She is currently being managed by our clinic, pain specialists and rehabilitation. A two-year recovery period is anticipated. Conclusions This case underscores the diagnostic challenge of vulvar pain in the context of a Tarlov cyst and emphasizes the necessity for heightened clinical suspicion and comprehensive evaluation. Additionally, the case highlights the importance of considering MRI of the lumbosacral spine as an early investigation in patients presenting with otherwise unexplained chronic vulvar pain, offering a valuable diagnostic tool for identifying conditions like Tarlov cysts that might otherwise remain elusive. Disclosure No.

Current insights and surgical interventions in craniovertebral junction instability

Abstract Background: The Craniovertebral Junction (CVJ) is prone to various pathologies, including instability and congenital anomalies. Understanding these conditions and their management strategies is critical for effective treatment. Materials and Methods: A systematic search was conducted in Science Direct and PubMed databases following PRISMA guidelines. Inclusion criteria encompassed studies addressing craniovertebral instability and associated pathologies. Six systematic investigations were assessed for methodological quality. Data extraction involved 702 patients with CVJ issues, among which 129 had related conditions, while 279 displayed normal CVJ. Surgical interventions encompassed various techniques such as C1-C2 fixation, posterior decompression, and screw placements. Results: Among 702 patients studied, atlantoaxial subluxation, basilar invagination, and odontoid fractures were observed in 129 cases. Surgical treatments showed favorable outcomes, with fusion achieved within a year post-surgery for both C1-C2 fixation techniques and posterior decompression strategies. Studies highlighted successful outcomes in cases of cervical myelopathy, especially with early occipitocervical fusion. Conclusion: Managing atlantoaxial instability remains a debated topic, with varying success rates observed in different surgical interventions. Recommendations emphasize the importance of stabilization techniques and imaging modalities for effective preoperative planning and postoperative care. However, limitations in the available data underscore the need for further research to refine treatment strategies for better patient outcomes in this complex area of spinal pathology. Keywords: Craniovertebral junction, atlantoaxial instability, Basilar invagination, fusion, CVJ pathologies

High Rate of Concomitant Lumbo-Sacral Spine Pathology in the Setting of Hip Abductor Tendon Repair

BackgroundHip abductor deficiency is a common cause of lateral hip pain in middle-aged patients. Identifying upstream muscle denervation originating in the lumbo-sacral spine could potentially impact the management of patients who have abductor deficiency. The purpose of this study was to estimate the prevalence of lumbo-sacral pathology (L4 to S1) in patients undergoing hip abductor tendon repair. MethodsAll cases of primary hip abductor repair performed at a tertiary care center between January 2010 and December 2021 were reviewed. Patients were classified into the following groups: A) confirmed L4 to S1 disease based on preoperative or perioperative L4 to S1 interventions (ie, surgery, epidural injections, and/or positive electromyography findings); B) radiographic evidence on lumbar spine magnetic resonance imaging demonstrating nerve compression at L4 to S1; and C) no evidence of L4 to S1 disease. ResultsThere were 131 cases of primary hip abductor repair that were included. Over 80% of patients were women, who had a mean age of 64 years (range, 20 to 85). There were thirteen patients (9.9%) who underwent concomitant total hip arthroplasty (THA). Of the included patients, 29% (n = 38) were categorized into group A, 12% (n = 16) into group B, and 59% (n = 77) into group C. Patients who had L4 to S1 pathology were older than patients who did not have L4 to S1 pathology (67 versus 61 years, P = .004). Of the patients undergoing concomitant THA and hip abductor repair, 54% demonstrated evidence of lumbo-sacral spine pathology. ConclusionsOver 40% of patients undergoing isolated hip abductor tendon repair and >50% of patients undergoing concomitant hip abductor tendon repair and THA demonstrated evidence of L4 to S1 disease perioperatively. Patients demonstrating symptomatic hip abductor deficiency should be screened for concomitant lower lumbo-sacral spine pathology.

Out-of-hours emergent surgery for degenerative spinal disease in Canada: a retrospective cohort study from a national registry

BackgroundSpinal degenerative disease represents a growing burden on our healthcare system, yet little is known about longitudinal trends in access and care. Our goal was to provide an essential portrait of surgical volume trends for degenerative spinal pathologies within Canada. MethodsThe Canadian Institute for Health Information (CIHI) database was used to identify all patients receiving surgery for a degenerative spinal condition from 2006 to 2019. Trends in number of interventions, unscheduled vs. scheduled hospitalizations, in-hours vs. out-of-hours interventions, resource utilization and adverse events were analyzed retrospectively using linear regression models. Confidence intervals were reported in the expected count ratio scale (CR). FindingsA total of 338,629 spinal interventions and 256,360 hospitalizations between 2006-2019 were analyzed. The mean and SD of the annual mean age of patients was 55.5 (SD 1.6) for elective hospitalizations and 55.6 (SD 1.6) for emergent hospitalizations. The proportion of female patients was 47.8% (91,789/192,027) for elective hospitalizations and 41.4% (26,633/64,333) for emergent hospitalizations. Elective hospitalizations increased an average of 2.0% per year, with CR=1.020 (95%CI 1.017 – 1.023, p<0.0001) while emergent hospitalizations exhibited more rapid growth with an average 3.4% annually, with CR 1.034 (95%CI 1.027 – 1.040, p<0.0001). «In-hours» surgeries increased on average 2.7% per year, with CR 1.027 (95%CI 1.021-1.033, p<0.0001), while «out-of-hours» surgeries increased 6.1% annually, with CR 1.061 (95%CI 1.051-1.071, p<0.0001). The resource utilization for unscheduled hospitalizations approximates two and a half times that of scheduled hospitalizations. The proportions of spinal interventions with at least one adverse event increased on average 6.3% per year, with CR 1.063 (95%CI 1.049-1.077, p<0.0001). InterpretationThis study provides novel data critical for all providers and stakeholders. The rapid growth of emergent out-of-hours hospitalizations demonstrates that the needs of this growing patient population have far exceeded health-care resource allocations. Future studies will analyze the health-related quality of life implications of this system shift and identify demographic and socioeconomic inequities in access to surgical care.

Evaluation of traumatic spinal injuries: a pediatric perspective.

The aim of the present study is to provide information about pediatric patients with spinal trauma. A single-center retrospective chart review was carried out. Children who arrived at the pediatric emergency department due to trauma and those with spinal pathology confirmed by radiological assessment were included. Demographics, mechanisms of trauma, clinical findings, radiological investigations, applied treatments, hospital stay and prognosis were recorded. A total of 105 patients [59 (56.2%) boys; mean age: 12.9 ± 3.8years (mean ± SD)] were included. The most common age group was that of 14-18years (58.1%). The three most common trauma mechanisms were road traffic collisions (RTCs) (60.0%), falls (32.4%), and diving into water (2.9%). A fracture of the spine was detected in 97.1% patients, vertebral dislocation in 10.7%, and spinal cord injury in 16.3%. Of the patients, 36.9% were admitted to the ward and 18.4% to the pediatric intensive care unit; 17.1% were discharged with severe complications and 2.9% cases resulted in death. While 34.3% of the patients had a clinically isolated spine injury, the remaining cases entailed an injury to at least one other body part; the most common associated injuries were to the head (39.8%), abdomen (36.1%), and external areas (28.0%). Spinal trauma was found to have occurred mostly in adolescent males, and the majority of those cases were due to RTCs. Data on the incidence and demographic factors of pediatric spinal trauma are crucial in furthering preventive measures, allowing for the identification of at-risk populations and treatment modalities.