Facet Joint Research Articles

Finite element analysis of the biomechanical effects of anterior and posterior cervical fusion surgery for bilateral cervical dislocation

Lower cervical spine injuries often manifest as lower cervical vertebral fractures and dislocations, as well as lower cervical facet joint dislocations. Especially in cases of bilateral facet joint dislocations, it is important to rapidly and effectively relieve spinal cord and nerve root compression to prevent secondary spinal cord injury, while also providing reliable and long-lasting stability to the injured segment after surgery. Combined anterior and posterior approaches have the advantages of both pure anterior or posterior approaches, but the actual situation is complex and variable, making systematic theoretical analysis crucial. This study, with bilateral facet joint dislocation of the C6 segment and cervical spinal cord injury as the research background, established a three-dimensional model of the cervical spine C3-C7 after implementing four types of anterior-posterior combined surgeries. The four surgical approaches consist of four combinations: anterior parallel or inclined screw placement combined with posterior Margel or Anderson method screw insertion. Through finite element method, a systematic comparative analysis of the theoretical effects of the four combined surgeries in treating bilateral facet joint dislocation of the cervical spine was conducted. The conclusion was that the variations in the four combined fixation methods have a certain impact on the biomechanical characteristics of the intervertebral disc nucleus. There is a clear mutual influence relationship among anterior and posterior fixation instruments. Based on the model used in this study, it is recommended to use a torque greater than 2.1 nm to tighten the locking nut of the posterior rod to ensure reliable internal fixation.

Abdominal Aortic Calcification is Associated with Degeneration of The Paraspinal Muscles - A Retrospective cross-sectional Study.

Retrospective cohort study. To analyze the relationship of abdominal aortic calcification (AAC) and a reduction in the cross-sectional area (CSA) and the fatty infiltration (FI) of the paravertebral muscles in patients undergoing lumbar fusion surgery. Both AAC and paraspinal muscle degeneration have been shown to be associated with poorer outcomes after surgical treatment of degenerative diseases of the lumbar spine. However, there is a lack of data on the association between AAC and paraspinal muscle changes in patients undergoing spine surgery. We retrospectively analyzed patients undergoing lumbar fusion for degenerative spinal pathologies. Muscular and spinal degeneration were measured on magnetic resonance imaging (MRI). AAC was classified on lateral lumbar radiographs. The association of AAC and paraspinal muscle composition was assessed by a multivariate regression analysis adjusted for age, sex, body mass index (BMI), comorbidities, and lumbar degeneration. A total of 301 patients was included. Patients with AAC showed significantly higher degrees of intervertebral disc and facet joint degeneration as well as higher total endplate scores at the L3/4 level. The univariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.530, P<0.001) and multifidus (b=0.730, P<0.001). The multivariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.270, P=0.006) and a significant negative correlation between the degree of AAC and the CSA of the psoas muscle (b=-0.260, P=0.003). This study demonstrates a significant and independent association between AAC and degeneration of the erector spinae and the psoas muscles in patients undergoing lumbar fusion. As both AAC and degeneration of paraspinal muscles impact postoperative outcomes negatively, preoperative assessment of AAC may aid in identifying patients at higher risk after lumbar surgery.

Identification of key eRNAs for intervertebral disc degeneration by integrated multinomial bioinformatics analysis

BackgroundIntervertebral disc degeneration (IVDD) is a common degenerative condition leading to abnormal stress distribution under load, causing intervertebral stenosis, facet joint degeneration, and foraminal stenosis. Very little is known about the molecular mechanism of eRNAs in IVDD.MethodsGene expression profiles of 38 annulus disc samples composed of 27 less degenerated discs (LDs) and 11 more degenerated discs (MDs) were retrieved from the GEO database. Then, differentially expressed enhancer RNAs (DEeRNAs), differentially expressed target genes (DETGs), and differentially expressed transcription factors (DETFs), hallmark of cancer signalling pathways according to GSVA; the types and quantity of immune cells according to CIBERSORT; and immune gene sets according to ssGSEA were analysed to construct an IVDD-related eRNA network. Then, multidimensional validation was performed to explore the interactions among DEeRNAs, DETFs and DEGs in space.ResultsA total of 53 components, 14 DETGs, 15 DEeRNAs, 3 DETFs, 5 immune cells, 9 hallmarks, and 7 immune gene sets, were selected to construct the regulatory network. After validation by online multidimensional databases, 21 interactive DEeRNA-DEG-DETF axes related to IVDD exacerbation were identified, among which the C1S-CTNNB1-CHD4 axis was the most significant.ConclusionBased upon the results of our study, we theorize that the C1S-CTNNB1-CHD4 axis plays a vital role in IVDD exacerbation. Specifically, C1S recruits CTNNB1 and upregulates the expression of CHD4 in IVDD, and subsequently, CHD4 suppresses glycolysis and activates oxidative phosphorylation, thus generating insoluble collagen fibre deposits and leading to the progression of IVDD. Overall, these DEeRNAs could comprise promising therapeutic targets for IVDD due to their high tissue specificity.

Osteoarthritis of zygapophysial joints as a cause of back pain and neck pain: a scoping review.

Zygapophysial joints (Z joints) can be a source of back pain and of neck pain, but the cause of pain is not known. Some authors attribute the pain to osteoarthritis but without citing evidence. The present review was undertaken to determine if there was sufficient evidence of association between spinal pain and osteoarthritis of Z joints to justify osteoarthritis being held to be the cause of pain. The null hypothesis was that osteoarthritis of Z joints does not cause back pain or neck pain. Relevant studies were ones that provided primary data on the association between pain and osteoarthritis of Z joints. These could be population studies, diagnostic studies, or case-control studies. The database of PubMed was searched using the terms: Lumbar or cervical, zygapophysial or facet, pain, and osteoarthritis or degeneration or degenerative. Data pertinent to the research question were extracted from original articles and tabulated for reporting. Odds ratios for associations were calculated, as were the prevalence rates of osteoarthritis in subjects with pain, and conversely the prevalence rates of pain in subjects with osteoarthritis. The searches retrieved 11 population studies, 4 diagnostic studies, and 3 cases control studies. No study showed any positive association between osteoarthritis of Z joints and pain. All studies found pain to be independent of the presence or severity of osteoarthritis. Osteoarthritis was as common in subjects with no pain as in subjects with pain. The null hypothesis was not refuted. The published evidence does not support the belief that osteoarthritis causes Z joint pain. All the evidence contradicts this belief.

Evidence for diagnostic blocks prior to radiofrequency ablation of innervation to the lumbar facet joints – none, once, or twice?

Evidence for diagnostic blocks prior to radiofrequency ablation of innervation to the lumbar facet joints – none, once, or twice?

Computed Tomography-Guided Facet Synovial Cyst Aspiration

Abstract Lumbar facet joint cysts are the benign collections of fluid at or around the facet joints, which may lead to pain and radicular symptoms. They may be associated with spinal stenosis, nerve root compression, neurogenic claudication, and many other neurological disturbances, as they can encroach on the adjacent neural foramen. Although the recommended treatment is surgical excision, percutaneous interventions provide an effective, acceptable, and safe alternative that may be considered. Hereby, we present the case of a 78-year-old patient known diabetic, hypertensive, and with deranged renal function, with left-sided L5 radiculopathy due to an L4-5 facet synovial cyst. He was treated through computed tomography (CT)-guided percutaneous aspiration and got long-term relief. The technique we used was different from the regular facet cyst aspiration, and the precision offered by CT guidance helped us provide optimum treatment leading to long-term relief. Thus, tailor-made treatment options rather than standard protocols for all patients allow a better risk–benefit ratio, in the field of pain management.

A clinical case of scapula fragment fracture with dislocation of fragments

Relevance. According to statistical data, fractures of the scapula are quite rare, accounting for approximately 3-5% of all shoulder girdle fractures and less than 1% of the total number of fractures. Because of the high-energy nature of scapula fractures, 80% to 95% of cases are associated with additional traumatic injuries. The aim: to analyze the technique of performing surgical intervention in a fragment fracture of the right scapula with displacement of the fragments on the example of a clinical case. Object and methods. Patient G., 21 years old, on 12.10.2023 applied to the trauma center № 114 after a wind-driven tree fell on his right forearm area. A fracture of the right scapula with displacement of the fragments was detected, the patient was referred to the emergency room of the R.R. Vreden Research and Development Center for further examination and treatment. On admission to the department, the patient's right supraclavicular region was longer than the left one, the right supraclavicular region at the acromial end was swollen and painful, without visible deformity. Results. The study presents traumatologic pathology, namely, fractures of the articular and clavicular processes of the scapula with displacement of the fragments, as well as fracture of the acromial process of the scapula with minimal displacement of the fragments and cranial subluxation of the acromial end of the clavicle. The causes, diagnostic methods and surgical treatment of this pathology are described. Conclusions. Due to the growing amount of data on satisfactory postoperative results in patients with scapula fractures, there is still interest in surgical trends in the treatment of these patients. However, it is worth remembering that postoperative complications after repositioning and fixation of bone fragments continue to be an urgent problem.

Radiofrequency Ablation of the Thoracic Descending Branch of the Posterior Rami: An Effective Intervention for Facet Joint Pain. A Case Report

BACKGROUND: Thoracic spine pain is believed to have a comparable prevalence to that of neck pain and low back pain in the general population. Recent discoveries in thoracic spine neuroanatomy have shown that the descending branch of the posterior ramus innervates the thoracic facet joint capsule. We present a case in which thermal radiofrequency ablation of the descending branch was used to significantly relieve pain in a patient with thoracic facet joint pain. CASE REPORT: A 57-year-old woman presented with a 4-month history of severe midthoracic back pain. The patient had failed initial conservative treatment including oral pain medications and physical therapy for 3 months. She ultimately elected for 2 bilateral diagnostic blocks of the T4-T6 descending branches and subsequent radiofrequency ablation; this treatment resulted in complete pain relief and functional improvement. CONCLUSIONS: Thoracic spine descending branch thermal radiofrequency ablation may be a treatment option for thoracic facet joint pain. KEY WORDS: Back pain, thoracic facet joint, descending branch, radiofrequency ablation, posterior ramus, thoracic spine, back, pain

Surgical Options for Bertolotti Syndrome

This article provides a comprehensive examination of Bertolotti syndrome (BS), a disorder characterized by back pain due to a lumbosacral transitional vertebra, to facilitate surgical decision-making by exploring various surgical options, including the innovative approach of endoscopic spine surgery. A review of existing literature and studies on BS published until December 2023 was undertaken, utilizing databases such as PubMed and Google Scholar to identify relevant information. The review offers an integrated overview of the essential knowledge of BS and a comprehensive range of surgical treatments. Symptomatic BS can manifest as pain originating from pseudoarticulation and the facet joints, discs, adjacent segments, and the L5 root, indicating a diverse distribution of pain sources. Furthermore, various surgical strategies are tailored to the specific origin of pain, including pseudoarticulation resection, transverse processectomy, decompression, nerve root decompression, fusion, and endoscopic spine surgery. For individuals with BS contemplating surgical solutions, performing a detailed assessment of symptoms and physical evaluations is imperative to accurately identify the origin of the pain. The choice of a surgical strategy must be meticulously customized according to the identified source of pain, guaranteeing a tailored and efficacious treatment for each patient.

Effective Management of Recurrent Trauma-Induced Neck Pain With Radiofrequency Neurotomy Using the Nimbus Electrosurgical Radiofrequency Multitined Expandable Electrode: A Case Report

BACKGROUND: Radiofrequency neurotomy (RFN) can be an effective treatment for patients with chronic neck pain and cervicogenic headaches resistant to conservative care. However, the degree and duration of pain relief after RFN is dependent upon the thoroughness of target nerve coagulation. CASE REPORT: This is a case of a 37-year-old patient with debilitating neck pain and headaches following a motor vehicle accident. Successful local anesthetic block of the third occipital nerve (TON) confirmed pain of C2-C3 facet joint origin. An initial RFN treatment of the TON, using standard 18G electrodes in bipolar mode, resulted in complete symptom amelioration for 8 months. Repeat RFN, using the same electrode configuration, was unsuccessful in alleviating the severe neck pain and headaches, and produced no demonstrable sensory loss in the distribution of the TON. RFN was then performed using the Nimbus® electrosurgical RF multitined expandable electrode, which provides a larger zone of coagulation in volume than standard RFN electrodes even when used in bipolar configuration. CONCLUSIONS: The Nimbus procedure resulted in successful coagulation of the TON with sensory loss in the TON distribution and reinstatement of palliative relief. KEY WORDS: Cervical pain, radiofrequency neurotomy, third occipital nerve, Nimbus, case report

Study of degenerative (non-lytic) spondylolisthesis grade 1 and 2 in axial MRI images

Background: The traditional imaging assessment of lumbar spondylolisthesis is in sagittal images noting movement of upper body over the lower body. It omits change at the facet. Methods: The present observational, study included 35 patients with degenerative lumbar spondylolisthesis(non-lytic). Radiological analysis of all MRI images was done by 4 independent spinal surgeons and 2 radiologists. The study focused on the axial MRI images and changed relation between the superior articular process and inferior articular process and relation between inferior articular process and canal with thecal sac (traversing root). Results: Majority of DS had sagittal oriented facets (71.43%). In 7 cases at the L3/4 and in 19 cases at L4/5 level both facet joints had sagittal orientation with forward (ventral) movement of IAP. The IAP was found to be encroaching or in close proximity of traversing root. In 1 patient at L3/4 and 6 patients at L4/5 joint was sagittal unilaterally, may be causing compression of the neural elements unilaterally, while on coronal side the IAP and SAP had a normal alignment and not causing neural encroachment Conclusions: We need to concentrate on relation of IAP vs SAP at facet as seen in axial images of facet.

Development of a Method for Estimating the Angle of Lumbar Spine X-ray Images Using Deep Learning with Pseudo X-ray Images Generated from Computed Tomography

Background and Objectives: In lumbar spine radiography, the oblique view is frequently utilized to assess the presence of spondylolysis and the morphology of facet joints. It is crucial to instantly determine whether the oblique angle is appropriate for the evaluation and the necessity of retakes after imaging. This study investigates the feasibility of using a convolutional neural network (CNN) to estimate the angle of lumbar oblique images. Since there are no existing lumbar oblique images with known angles, we aimed to generate synthetic lumbar X-ray images at arbitrary angles from computed tomography (CT) images and to estimate the angles of these images using a trained CNN. Methods: Synthetic lumbar spine X-ray images were created from CT images of 174 individuals by rotating the lumbar spine from 0° to 60° in 5° increments. A line connecting the center of the spinal canal and the spinous process was used as the baseline to define the shooting angle of the synthetic X-ray images based on how much they were tilted from the baseline. These images were divided into five subsets and trained using ResNet50, a CNN for image classification, implementing 5-fold cross-validation. The models were trained for angle estimation regression and image classification into 13 classes at 5° increments from 0° to 60°. For model evaluation, mean squared error (MSE), root mean squared error (RMSE), and the correlation coefficient (r) were calculated for regression analysis, and the area under the curve (AUC) was calculated for classification. Results: In the regression analysis for angles from 0° to 60°, the MSE was 14.833 degree2, the RMSE was 3.820 degrees, and r was 0.981. The average AUC for the 13-class classification was 0.953. Conclusion: The CNN developed in this study was able to estimate the angle of an lumbar oblique image with high accuracy, suggesting its usefulness.

Imaging anatomy study related to unilateral biportal endoscopic lumbar spine surgery.

To provide lumbar spine anatomical parameters relevant to the UBE technique and explore their intraoperative application. CT imaging data processed by Mimics for parametric measurements, including laminar abduction angle (LAA), laminar slope angle (LSA), minimum laminar height (MLH), distance between the inferior margin of the lamina and attachment of the ligamentum flavum onto the cephalad lamina (DLL), distance between the initial point and the middle of the articular process (DIA), and distance from the inferior margin of the lamina to the inferior border of the vertebral body (DLV), and were manually measured. LAA and DIA gradually increase from L1 to L5. At L1, the DIA is approximately the length of 2 drill bits with a diameter of 3mm (male: 7.77 ± 1.39mm, female: 7.22 ± 1.09mm), while at L5, it can reach the length of 4-5 drill bits (male: 14.96 ± 2.24mm, female: 13.67 ± 2.33mm). MLH, DLL, and DLV reach their maximum values at the L3 and decrease toward the cranial and caudal ends. The DLL is smallest at L5 (male: 9.58 ± 1.90mm, female: 9.38 ± 2.14mm), equivalent to the length of 3 drill bits, while the DLL at L3 is the length of 4-5 drill bits (male: 14.17 ± 2.13mm, female: 14.01 ± 2.07mm). Referring to the drill diameter during surgery can mark the extent of laminotomy. The characteristics of vertebral plate angles at different lumbar levels can provide references for preoperative incision design.

Exploring the Influence of Facet Orientation and Tropism on Neutral Zone Properties.

Lumbar spine pathologies have been linked independently to both neutral zone (NZ) properties and facet joint anatomical characteristics; however, the effect of facet joint orientation (FO) and tropism (FT) on NZ properties remains unclear. The aim of the present study was to investigate how axial plane FO and FT relate to NZ range and stiffness in the human lumbar spine and porcine cervical spine. Seven human lumbar functional spine units (FSUs) and 94 porcine cervical FSUs were examined. FO and FT were measured, and in vitro mechanical testing was used to determine anterior-posterior (AP) and flexion-extension (FE) NZ range and stiffness. FO and FT were found to have no significant relationship with AP and FE NZ range. Increases in FT were associated with greater FE and AP NZ stiffness in human FSUs, with no FT-NZ stiffness relationship observed in porcine specimens. A significant relationship (p < 0.001) between FO and FE NZ stiffness was observed for both porcine and human FSUs, with a more sagittal orientation of the facet joints being associated with decreased FE NZ stiffness. Given the link between NZ stiffness and pathological states of the lumbar spine, further research is warranted to determine the practical significance of the observed facet joint anatomical characteristic-NZ property relationship.

Percutaneous Endoscopic Suprapedicular Decompression in the Treatment of Down-Migrated Lumbar DiscHerniation

[OBJECTIVE]: This study aimed to investigate the clinical efficacy of percutaneous endoscopic suprapedicular decompression in treatment of down-migrated lumbar disc herniation. [METHODS]: The clinical data of 43 patients with down-migrated lumbar disc herniation treated with endoscopic surgery at our hospital between January 2022 and January 2023 were retrospectively analysed. Twenty-two and 21 patients underwent percutaneous endoscopic decompression using the suprapedicular and TESSYS approaches, respectively. The perioperative, follow-up, and imaging data of the groups were compared. [RESULTS]: Surgery was uneventful in both groups. The number of intraoperative fluoroscopies and duration of surgery were significantly lower in the suprapedicular group (p<0.05). The patients in both groups were followed up for at least 12 months. At the last follow-up, lumbar pain and leg pain visual analogue scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short Form Health Survey (SF-36) scores were significantly improved in both groups compared with preoperative values (p<0.05); the differences in these indexes between the two groups were not significant preoperatively (p>0.05). However, at the last postoperative follow-up, lumbar pain VAS scores were significantly better in the suprapedicular group (0.83±0.85 vs. 2.54±1.32, p<0.05). There was no significant change in intervertebral space height or lumbar lordotic angle compared with preoperative values in either group at the last follow-up (p>0.05). However, the spinal canal cross-sectional area significantly increased (p<0.05). [CONCLUSION]: The treatment of down-migrated lumbar disc herniation via a suprapedicular approach enabled the incision of the superior margin of the pedicle as needed under direct vision, involved less fluoroscopy while preserving facet joint stability, and enabled targeted removal of the herniated nucleus pulposus, thus greatly reducing residual nucleus pulposus. This surgical procedure was safe, rapid, and showed satisfactory therapeutic efficacy.

Three Stages on Magnetic Resonance Imaging of Lumbar Degenerative Spine

PurposesTo propose a new lumbar degenerative staging system using the current radiological classification system. MethodsA cross-sectional analysis of retrospective databases between January 2018 and December 2022 was performed. 410 Patients for Modic changes, paravertebral muscle fat infiltration, disc degeneration, articular process degeneration, vertebral endplate degeneration and other structures and disc displacement, Spondylolisthesis, and Stenosis, and grouped patients according to stage were assessed. Visual analogue scale (VAS), Japanese Orthopaedic Association (JOA), and Oswestry Disability Index (ODI) scores were used to assess LBP strength, neurological function, and quality of life, respectively. ResultsThe lumbar degeneration staging system consists of 8 variables, which can be divided into three steps: early, middle and late, and the correlation between each variable is strong (p<0.05). The later the staging, the worse the JOA, VAS and ODI scores. ConclusionsPatients with later stages have worse clinical scores. This staging system recommends a uniform classification to assess lumbar degeneration.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries

IntroductionTraumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF).MethodsA retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified.ResultsPatients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure.ConclusionsACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

E046 Lytic lesions; metastatic disease or gout?

Abstract Background/Aims Uric acid crystal deposition in the spine is uncommonly diagnosed, although the frequency of axial involvement is thought to be as high as 14-35%. Studies have shown that spinal gout is more common in men aged 35-75 years, with a history of chronic polyarticular tophaceous gout which is not optimally controlled being a key risk factor. Recent studies have shown that spinal gout is under and misdiagnosed due to its non-specific presentation of back pain or absence of symptoms. Our case report exemplifies this diagnostic challenge. Methods In this report we describe a case of a 79-year-old male with a history of polyarticular tophaceous gout, chronic kidney disease and previous renal carcinoma treated with curative radiotherapy. He presented with a 4-week history of progressive exertional dyspnoea and orthopnoea. He was commenced on intravenous diuretics which lead to an acute kidney injury, with his eGFR dropping to 14mL/min. His preadmission allopurinol and colchicine were held and clinically he developed a flare of gout affecting his right wrist and right second and third MCP joints. A CT scan of his abdomen and pelvis, carried out to investigate potential bowel obstruction, showed no evidence of obstruction but it did reveal multiple lytic lesions in the spine with potential extension into the spinal canal at T9 and L5. He did not have any back pain and his neurological examination was normal. Results A working diagnosis of spinal metastasis with potential cord compression was made and the patient was commenced on high dose steroids. He subsequently underwent an MRI whole spine which showed marrow abnormalities and destructive soft tissues changes affecting various facet joints in the thoracic and lumbar spine. The primary differential remained metastases but due to the unusual distribution of the marrow changes in which the vertebral bodies were completely spared, the initial CT images were reviewed on spectral scanning which demonstrated uric acid deposition in the affected facet joints. The diagnosis was confirmed as gout in the spine when a PET-CT scan revealed no potential primary source of malignancy. The gout flare in his hand settled with the steroids prescribed to treat the potential cord compression and he continued to deny suffering from back pain. Conclusion A literature search demonstrates that reports of spinal gout being described as lytic lesions on CT are rare. Spinal gout should be considered as a differential in a patient with facet joint lytic lesions on imaging, without involvement of the vertebral body and where no primary malignancy is found. Our case demonstrates how dual energy CT scanning can prevent the need for invasive biopsy in cases of diagnostic uncertainty in patients with a history of poorly controlled chronic tophaceous gout. Disclosure S.K. Stewart: None. D.J. Coulter: None. C. Masih: None.

E048 Spinal gout: an unusual cause of paraplegia

Abstract Background/Aims Gout is a common inflammatory arthritis caused by the deposition of monosodium urate crystals. Gout usually causes peripheral joint arthritis. Axial involvement is likely under-recognised, affecting an estimated 10-20% of gout patients. Spinal gout is an established phenomenon in patients with chronic tophaceous gout and sustained hyperuricaemia. Gout can affect any segment of the spine. Clinical presentation of spinal gout is variable including back pain, radiculopathy and cord compression. Due to its nonspecific presentation, it can be confused for other spinal pathologies such as epidural abscess, malignancy, spondylodiscitis and vertebral osteomyelitis. Methods We present a case report of a young male with tophaceous gout of the thoracic spine. Results A 37 year old man presented with 4 day history of acute thoracic back pain followed by flaccid lower limb paralysis. He was morbidly obese (BMI 60) and had a 13-year history of poorly controlled gout with most recent uric acid being 627. He had previously declined urate lowering therapy but commenced allopurinol treatment one month prior to admission. On examination power was 0/5 in both lower limbs with absent reflexes and a T12 sensory level. MRI showed multi-level facet joint arthropathy. An epidural collection was present at T8-10, causing complete occlusion of the vertebral artery. He underwent an urgent posterior thoracic decompression. ‘White cheese like epidural pus’ was removed and he was initially treated as facet joint infection. He had ongoing fevers [&amp;gt;38.5C], despite empirical antibiotics, and C-reactive-protein was persistently elevated [highest at 360mg/L]. Uric acid was 423. Enrichment culture of the epidural collection and serial blood cultures were negative. Repeat MRI of spine did not demonstrate any reoccurrence of collection. Subsequently the histology of the epidural collection was reported as characteristic of gout with ‘amorphous material and giant cells’. No urate crystals were identified as the sample was prepared with formalin, which would have dissolved any crystals present. He was referred to rheumatology who identified synovitis in his hands, wrist and elbows, consistent with active polyarticular gout. There were small tophi present on his heels and pinna. The patient was commenced on oral prednisolone and allopurinol was rapidly up-titrated. Unfortunately, the patient did not recover neurological function. Conclusion We present a unique case of acutely presenting tophaceous thoracic spinal gout causing irreversible paraplegia in a young patient, mimicking an epidural abscess. Our patient had hyperuricaemia for over 10 years without treatment, raising his risk of axial complications. A high index of suspicion for spinal gout is needed for patients presenting with acute back pain and neurological symptoms with a history of chronic gout. This case highlights diagnostic challenges in identifying spinal gout and the importance of treating tophaceous gout early to prevent devastating long-term complications. Disclosure C.A. Zollinger-Read: None. M. Cox: None. R. Kumari: None.

Interventional diagnosis and treatment methods of discogenic and musculoskeletal low back pain

Low back pain (lumbar pain) is one of the most common causes of disability in the population. In cases where conservative treatment of discogenic or musculoskeletal low back pain does not have a positive effect, interventional methods of diagnosis and treatment are used, which are developing actively on the background of rapid technological progress. Being on the border of interdisciplinary interaction, interventional methods can significantly shorten the duration of conservative therapy and, in many cases, avoid surgical decompressive interventions, which are associated with a considerable risk of complications. The methods, efficacy and safety of epidural administration of glucocorticoids for discogenic radiculopathy and lumbar stenosis as well as the methods of radiofrequency denervation for musculoskeletal pain due to the facet joints and the sacroiliac joint involvement are discussed. The possibilities of drug therapy for musculoskeletal pain of the lumbar spine, and combination of non-steroidal anti-inflammatory drugs and a vitamin B complex, are discussed.