Simvastatin and Simvastatin-Ezetimibe Improve the Neurological Function and Attenuate the Endothelial Inflammatory Response after Spinal Cord Injury in Rat.

During a spinal cord injury (SCI), mechanical trauma rapidly leads to a blood-spinal cord barrier (BSB) disruption, neural cell damage, axonal damage, and demyelination, followed by a cascade of secondary inflammatory reactions. These inflammatory responses spread the damage to the neural cells and impair the recovery of neurological functions. In the present study, we evaluated the efficacy of simvastatin and a simvastatin-ezetimibe combination therapy in managing the endothelial inflammatory response in an SCI rat model. Adult male Sprague-Dawley rats were group-housed and SCI was induced by using the modified weight-drop method. The animals were divided into 4 groups: (1) sham group, laminectomy only (n=6); (2) no-treatment group, SCI without therapy (n=8); (3) simvastatin group (n=8), and (4) ezetimibe and simvastatin combination therapy group (n=8). A high dose (15 mg/kg) of simvastatin was given to the simvastatin group, and 10 mg/kg simvastatin and 10 mg/kg ezetimibe were given to the combination group. Neurological function was assessed using the Basso, Beattie, and Bresnahan locomotor scale score. Intercellular adhesion molecule-1 (ICAM-1) level was used as an SCI biomarker. ICAM-1 level was the highest at 72 hours after SCI in the no-treament group. The treatment groups showed significant reduction in ICAM-1 levels at 72 hours. The treatment groups, especially the combination treatment group, showed better neurological function scores. Simvastatin and simvastatin- ezetimibe all could improve the neurological function and attenuate the endothelial inflammatory response after spinal cord injury in rat.

Fluoroscopically-Guided Superior Hypogastric Plexus Neurolysis Using a Single Needle: A Modified Technique for a Posterolateral Transdiscal Approach.

BACKGROUND: A superior hypogastric plexus block is difficult to perform and hampered by bony structures of the iliac crest and transverse process of L5. OBJECTIVE: We report on a fluoroscopically guided posterolateral transdiscal technique for superior hypogastric plexus neurolysis using a single needle. STUDY DESIGN: A technical note describing interventional procedures. SETTING: The neurosurgery department of a cancer hospital. METHODS: The patient was placed in the prone position with a pillow beneath the iliac crest to facilitate opening of the intervertebral disc. The entry point for the needle was 7-8 cm to the left of the midline of the L45 level. The spinal needle was slightly advanced caudally toward the L5-S1 disc and at a 40° angle from the vertical plane. Using lateral fluoroscopic control, the needle was advanced beneath the inferior aspect of the facet joint. After entering the disc, the needle was then advanced until it passed the anterior annulus fibrosus of the L5S1 disc. After verifying adequate position using contrast, 3 mL of 75% ethanol was injected for neurolysis. RESULTS: During the follow-up, the patient reported reduction of pain in the lower abdomen and quality of life was significantly improved. LIMITATIONS: Sample size; no placebo control. CONCLUSION: Although different approaches exist, we prefer the posterolateral transdiscal approach for superior hypogastric plexus block and neurolysis using a single needle. This technique is a valuable alternative. KEY WORDS: Superior hypogastric plexus neurolysis, transdiscal approach, cancer pain.

Comparative Cost Analysis for the Surgical and Endovascular Treatment of Ruptured Intracranial Aneurysms in Taiwan: A Nationwide Population-Based Cohort Study.

OBJECTIVE: Using a database that enabled longitudinal follow-up, we assessed the cost, outcome, complications, and readmission rate of ruptured cerebral aneurysms repaired by surgical clipping and endovascular coiling. METHODS: This study was a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of ruptured cerebral aneurysms between 1996 and 2013. The medical records and hospital cost data were all examined. RESULTS: A total of 7690 and 1380 cases were treated with clipping and coiling, respectively. Patients treated with clipping had more comorbidities and were older. The average total cost for endovascular coiling was $13,974.3, whereas the average total cost for surgical clipping was $16,581.7. Perioperative (30-day) mortality was 10.7% in patients with coiled aneurysms, compared with 12.6% in those with clipped aneurysms (P = 0.045). After 1 year of follow-up, clipping was associated with a significantly longer length of hospital stay (P < 0.001) and significantly higher total hospital costs (P < 0.001). CONCLUSIONS: In Taiwan, the total hospital costs for the surgical clipping of cerebral aneurysms were higher than for endovascular coiling, and the surgical results were associated with significant complications. We suggest that the indications for coiling might need to be expanded from the current standards dictated by the guidelines in Taiwan.

Risk of dementia in patients with primary insomnia: a nationwide population-based case-control study.

BACKGROUND: To investigate the association between primary insomnia and dementia using a Taiwanese population-based database. METHODS: This case-control study involved a subset of Taiwan's National Health Insurance Research Database of reimbursement claims. We included 51,734 patients who were diagnosed with primary insomnia from 2002 to 2004 as the test group and 258,715 nonprimary insomnia participants aged 20 years or older as the reference group. We excluded patients under 20 and those with depression, post-traumatic stress disorder, and/or sleep disorders caused by organic lesion(s), drugs, or alcohol. We used a Cox proportional hazards model to assess the primary insomnia on the risk of developing dementia after adjusting for sociodemographic characteristics and comorbidities. RESULTS: The primary insomnia cohort had a higher prevalence of diabetes, dyslipidemia, hypertension, coronary heart disease, chronic liver disease, and chronic kidney disease at baseline. After adjusting for select comorbidities, primary insomnia remained a significant predisposing factor for developing dementia, and was associated with a 2.14-fold (95% confidence interval, 2.01-2.29) increase in dementia risk. We also found a higher risk of dementia in younger patients. CONCLUSIONS: Taiwanese patients with primary insomnia, especially those under 40, had a higher risk of developing dementia than those without primary insomnia.

Population-based study suggests an increased risk of Alzheimer'sdisease in Sjögren's syndrome.

This population-based study was designed to estimate and compare the risk of Alzheimer's disease (AD) between patients with primary Sjögren's syndrome (SS) and non-SS patients during a 10-year follow-up period. This is a retrospective cohort study. Data were obtained from the Taiwan's National Health Insurance Research Database. We identified 4463 primary SS patients and 22,315 non-SS patients; patients were matched by sex, age, and the year of index use of health care. Each patient was studied to identify the subsequent manifestation of AD. Cox proportional hazard regression was used to study the subsequent manifestation of AD, and Kaplan-Meier survival curves were used to compare survival probability. During the 10-year follow-up period, 7 primary SS and 13 non-SS patients developed AD. During the 10-year follow-up period, the risk of AD was 2.68-fold higher in the primary SS cohort with an overall adjusted hazard ratio (HR) of 2.69 (95% CI 1.07-6.76), after adjusting for demographics and comorbidities. Within the 10-year period, patients with primary SS showed a 2.69-fold increased risk of developing AD. This risk increases with time, and the relative risk of AD is higher in older patients with primary SS.

TDP-43 proteolysis is associated with astrocyte reactivity after traumatic brain injury in rodents.

The aggregation and deposition of transactivation response DNA-binding protein 43 (TDP-43) in neurons and astrocytes is characteristic in a number of neurodegenerative diseases including Alzheimer's disease, frontotemporal lobar degeneration, and amyotrophic lateral sclerosis. Nevertheless, the exact role of TDP-43 in astrocytes is unknown. Recently, TDP-43 was identified in neurons but not astrocytes after traumatic brain injury (TBI) in humans. In the present study, we evaluated TDP-43 expression and proteolysis in astrocytes in a rat model of TBI. We assessed TDP-43 fragment expression, astrocyte morphology, neuronal population numbers, and motor function after TBI with or without intracerebroventricular administration of a caspase-3 inhibitor. Motor dysfunction was observed after TBI in potential association astrocytic TDP-43 short fragment mislocalization and accumulation, astrogliosis, and neuronal loss. Notably, caspase-3 inhibition prevented these changes after TBI. Our findings suggest that TDP-43 proteolysis in astrocytes is related to astrogliosis and subsequent neuronal loss in TBI, and that TDP-43 may be an important therapeutic target for preventing motor dysfunction after TBI.

Risk factors for myocardial dysfunction after traumatic brain injury: A one-year follow-up study.

INTRODUCTION: Traumatic brain injury has been associated with an increased risk of myocardial dysfunction. Common abnormalities accompanying this pathology include electrocardiographic abnormalities, elevated creatine kinase levels, arrhythmias, and pathologic changes of the myocardium. The aim of this study was to determine if TBI patients have a higher risk of myocardial dysfunction than the general population and to identify the risk factors of myocardial dysfunction in TBI patients. PATIENTS AND METHODS: The study sample was drawn from Taiwan's National Health Insurance Research Database of reimbursement claims, and comprised 26,860 patients who visited ambulatory care centers or were hospitalized with a diagnosis of TBI. The comparison group consisted of 134,300 randomly selected individuals. The stratified Fine and Gray regression was performed to evaluate independent risk factors for myocardial dysfunction in all patients and to identify risk factors in TBI patients. RESULTS: During a 1-year follow-up period, 664 patients with TBI and 1494 controls developed myocardial dysfunction. TBI was independently associated with increased risk of myocardial dysfunction. Diabetes, hypertension, peptic ulcer disease, chronic liver disease and chronic renal disease were risk factors of myocardial dysfunction in TBI patients. CONCLUSIONS: Individuals with TBI are at greater risk of developing myocardial dysfunction after adjustments for possible confounding factors. Early monitor should be initiated to decrease disability and dependence in patients with TBI.

Analysis of Patients with Myelopathy due to Benign Intradural Spinal Tumors with Concomitant Lumbar Degenerative Diseases Misdiagnosed and Erroneously Treated with Lumbar Surgery.

OBJECTIVE: When a cervical or thoracic benign intradural spinal tumor (BIST) coexists with lumbar degenerative diseases (LDD), diagnosis can be difficult. Symptoms of BIST-myelopathy can be mistaken as being related to LDD. Worse, an unnecessary lumbar surgery could be performed. This study was conducted to analyze cases in which an erroneous lumbar surgery was undertaken in the wake of failure to identify BIST-associated myelopathy. METHODS: Cases were found in a hospital database. Patients who underwent surgery for LDD first and then another surgery for BIST removal within a short interval were studied. Issues investigated included why the BISTs were missed, how they were found later, and how the patients reacted to the unnecessary lumbar procedures. RESULTS: Over 10 years, 167 patients received both surgeries for LDD and a cervical or thoracic BIST. In 7 patients, lumbar surgery preceded tumor removal by a short interval. Mistakes shared by the physicians included failure to detect myelopathy and a BIST, and a hasty decision for lumbar surgery, which soon turned out to be futile. Although the BISTs were subsequently found and removed, 5 patients believed that the lumbar surgery was unnecessary, with 4 patients expressing regrets and 1 patient threatening to take legal action against the initial surgeon. CONCLUSIONS: Concomitant symptomatic LDD and BIST-associated myelopathy pose a diagnostic challenge. Spine specialists should refrain from reflexively linking leg symptoms and impaired ability to walk to LDD. Comprehensive patient evaluation is fundamental to avoid misdiagnosis and wrong lumbar surgery.

The risk of cataractogenesis after gamma knife radiosurgery: a nationwide population based case-control study.

BACKGROUND: Medical radiation is considered a factor responsible for cataractogenesis. However, the incidence of this ophthalmologic complication resulting from gamma knife radiosurgery (GKRS) has not yet been reported. The present study aimed to determine the risk of cataractogenesis associated with radiation exposure from GKRS. METHODS: This study used information from a random sample of one million persons enrolled in the nationally representative Taiwan National Health Insurance Research Database. The GK group consisted of patients who underwent GKRS between 2000 and 2009. The non-GK group was composed of subjects who had never undergone GKRS, but who were matched with the case group for time of enrollment, age, sex, history of coronary artery disease, hypertension, and diabetes. RESULTS: There were 277 patients in the GK group and 2770 matched subjects in the non-GK group. The GK group had a higher overall incidence of cataracts (10.11% vs. 7.26%; crude hazard ratio [cHR], 1.59; 95% CI, 1.07-2.36; adjusted hazard ratio [aHR], 1.25; 95% CI, 0.82-1.90) than the non-GK group. Patients who had undergone computed tomography and/or cerebral angiography (CT/angio) studies had a higher risk of developing cataracts than those who did not (10.82% vs. 6.64%; cHR, 1.74; 95% CI, 1.31-2.30; aHR, 1.65; 95% CI, 1.22-2.23). The age group between 30 and 50 years had the highest risk of cataractogenesis in both the GK and CT/angio groups (cHR, 3.50; 95% CI, 1.58-7.72; aHR, 2.43; 95% CI, 1.02-5.81; cHR, 2.96; 95% CI, 1.47-5.99; aHR, 2.27; 95% CI, 1.05-4.93, respectively). CONCLUSIONS: Radiation exposure due to GKRS and CT/angio study may be independently associated with increased risk of cataractogenesis. We suggest routine dosimetry measurement of eye lens and proper protection for patients with benign lesions during GKRS. Regular follow-up imaging studies should avoid the use of CT/angio, and particular care should be taken in the 30-50-year-old age group, due to their significantly increased risk of cataract formation.

Nucleoplasty for treating lumbar disk degenerative low back pain: an outcome prediction analysis.

PURPOSE: Nucleoplasty is a minimally invasive technique that is considered efficacious in alleviating lumbar disk degenerative low back pain (LBP). The efficacy of nucleoplasty and identified variables that can predict pain relief for nucleoplasty was reported. PATIENTS AND METHODS: Between December 2013 and November 2015, 47 nucleoplasty procedures on 47 lumbar disks in 31 consecutive patients were performed. The outcome was evaluated using a visual analog scale (VAS) score. Improvements of ≥50% in VAS scores were considered substantial pain relief. The variables associated with pain relief after nucleoplasty included: 1) age; 2) sex; 3) body mass index; 4) hyperintensity zone at the rear of the disk; 5) hypointensity of the disk; 6) Modic changes of the end plates; 7) spinal instability pain; and 8) discography results. RESULTS: Twenty-one patients (67.7%) experienced substantial pain relief. The most common side effects following nucleoplasty were soreness at the needle puncture site (64.5%), numbness in the lower leg (12.9%), and increased intensity of back pain (9.7%). All side effects were transient. Multivariate analysis revealed that the discography results were the most critical predictor for substantial pain relief of nucleoplasty (P=0.03). The sensitivity and specificity of discography were 92.8% and 62.5%, respectively. CONCLUSION: Discography results could improve the success rate of nucleoplasty in the treatment of disk degenerative LBP.

Clinical outcome following DIAM implantation for symptomatic lumbar internal disk disruption: a 3-year retrospective analysis.

BACKGROUND/OBJECTIVE: Internal disk disruption (IDD), an early event of lumbar disk degeneration, is the most common cause of low back pain. Since increased intradiskal pressure (IDP) is associated with symptoms and progression of disk degeneration, unloading a painful disk with an interspinous process device (IPD) is a rational treatment option. The goal of this study was to evaluate the effectiveness of dynamic stabilization with an IPD in the treatment of symptomatic IDD of the lumbar spine. PATIENTS AND METHODS: Patients with symptomatic IDD were treated with implantation of an IPD, the device for intervertebral assisted motion (DIAM). Diagnosis of IDD was based on typical MRI finding of posterior annular high-intensity zone and positive provocative test on discography. IDP was analyzed intraoperatively. Axial back and leg pain was evaluated with visual analog scale, functional status with Oswestry Disability Index, and final clinical outcomes with Odom criteria. Data from 34 patients followed up for at least 3 years were collected. RESULTS: DIAM implantation significantly reduced IDP (n=11, P<0.0001). All 34 patients reported symptom relief. Thirty-one patients (91%) remained symptom free until the last followups. Three patients (9%) experienced recurrence of pain, of which the causes were unrelated to the IDD or surgery. Disk status at the DIAM-implanted segments remained stable. Segmental flexion/extension mobility was preserved in 27 of 30 patients with preoperative mobility. No proximal or distal adjacent segment degeneration was observed. The final clinical outcomes were excellent/good in 31 and fair/poor in three patients. CONCLUSION: For patients with symptomatic IDD, dynamic stabilization with DIAM provides pain relief and functional improvement. The implantation maintains disk status and prevents progression of disk degeneration, without compromising segmental flexion/extension mobility or causing adjacent segment degeneration.

Fluoroscopically Guided C2 Percutaneous Vertebroplasty: A Surgical Technique Note on an Anterior Ascending Approach.

BACKGROUND: C2 vertebroplasty is more challenging than transpedicular percutaneous vertebroplasty in the thoracic and lumbar spine. OBJECTIVE: We report an anterior ascending approach for C2 percutaneous vertebroplasty to avoid potential injury to vital structures surrounding the C2 vertebra. STUDY DESIGN: A technique note with 5 consecutive cases. SETTING: Neurosurgery department of a university hospital. METHODS: Fluoroscopically guided manual compression was applied using 3 fingers at the C5 level between the muscle and trachea. The larynx and trachea were displaced medially and the carotid artery laterally. The anterior cervical spine was palpated, and a 15-gauge 4-inch bone marrow biopsy needle was introduced through an anterior ascending approach. When the tip touched the intervertebral disc between C2 and C3, the needle was pushed through the disc until it penetrated into the C2 vertebral body. After confirming adequate needle insertion, vertebroplasty was performed. RESULTS: Pain relief was achieved in 4/5 (80%) patients. One patient possibly did not benefit from percutaneous vertebroplasty, and asymptomatic cement extravasation was detected in 2 patients. LIMITATIONS: Sample size; impossibility of placebo control. CONCLUSION: An anterior ascending approach for C2 percutaneous vertebroplasty is a valuable alternative for relieving pain caused by metastatic spinal tumors. This approach is familiar to surgeons performing anterior cervical discectomies, percutaneous nucleoplasty, or odontoid screw placement surgeries. KEY WORDS: Vertebroplasty, pain, axis, cement leak, metastases, palliative medicine, spine, fracture.

Reduction in adjacent-segment degeneration after multilevel posterior lumbar interbody fusion with proximal DIAM implantation.

OBJECT Multilevel long-segment lumbar fusion poses a high risk for future development of adjacent-segment degeneration (ASD). Creating a dynamic transition zone with an interspinous process device (IPD) proximal to the fusion has recently been applied as a method to reduce the occurrence of ASD. The authors report their experience with the Device for Intervertebral Assisted Motion (DIAM) implanted proximal to multilevel posterior lumbar interbody fusion (PLIF) in reducing the development of proximal ASD. METHODS This retrospective study reviewed 91 cases involving patients who underwent 2-level (L4-S1), 3-level (L3-S1), or 4-level (L2-S1) PLIF. In Group A (42 cases), the patients received PLIF only, while in Group B (49 cases), an interspinous process device, a DIAM implant, was put at the adjacent level proximal to the PLIF construct. Bone resection at the uppermost segment of the PLIF was equally limited in the 2 groups, with preservation of the upper portion of the spinous process/lamina and the attached supraspinous ligament. Outcome measures included a visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI) for functional impairment. Anteroposterior and lateral flexion/extension radiographs were used to evaluate the fusion status, presence and patterns of ASD, and mobility of the DIAM-implanted segment. RESULTS Solid interbody fusion without implant failure was observed in all cases. Radiographic ASD occurred in 20 (48%) of Group A cases and 3 (6%) of Group B cases (p < 0.001). Among the patients in whom ASD was identified, 9 in Group A and 3 in Group B were symptomatic; of these patients, 3 in Group A and 1 in Group B underwent a second surgery for severe symptomatic ASD. At 24 months after surgery, Group A patients fared worse than Group B, showing higher mean VAS and ODI scores due to symptoms related to ASD. At the final follow-up evaluations, as reoperations had been performed to treat symptomatic ASD in some patients, significant differences no longer existed between the 2 groups. In Group B, flexion/extension mobility at the DIAM-implanted segment was maintained in 35 patients and restricted or lost in 14 patients, 5 of whom had already lost segmental flexion/extension mobility before surgery. No patient in Group B developed ASD at the segment proximal to the DIAM implant. CONCLUSIONS Providing a dynamic transition zone with a DIAM implant placed immediately proximal to a multilevel PLIF construct was associated with a significant reduction in the occurrence of radiographic ASD, compared with PLIF alone. Given the relatively old age and more advanced degeneration in patients undergoing multilevel PLIF, this strategy appears to be effective in lowering the risk of clinical ASD and a second surgery subsequent to PLIF.

Repeated vertebral augmentation for new vertebral compression fractures of postvertebral augmentation patients: a nationwide cohort study.

PURPOSE: Postvertebral augmentation vertebral compression fractures are common; repeated vertebral augmentation is usually performed for prompt pain relief. This study aimed to evaluate the incidence and risk factors of repeat vertebral augmentation. METHODS: We performed a retrospective, nationwide, population-based longitudinal observation study, using the National Health Insurance Research Database (NHIRD) of Taiwan. All patients who received vertebral augmentation for vertebral compression fractures were evaluated. The collected data included patient characteristics (demographics, comorbidities, and medication exposure) and repeat vertebral augmentation. Kaplan-Meier and stratified Cox proportional hazard regressions were performed for analyses. RESULTS: The overall incidence of repeat vertebral augmentation was 11.3% during the follow-up until 2010. Patients with the following characteristics were at greater risk for repeat vertebral augmentation: female sex (AOR=1.24; 95% confidence interval [CI]: 1.10-2.36), advanced age (AOR=1.60; 95% CI: 1.32-2.08), diabetes mellitus (AOR=4.31; 95% CI: 4.05-5.88), cerebrovascular disease (AOR=4.09; 95% CI: 3.44-5.76), dementia (AOR=1.97; 95% CI: 1.69-2.33), blindness or low vision (AOR=3.72; 95% CI: 2.32-3.95), hypertension (AOR=2.58; 95% CI: 2.35-3.47), and hyperlipidemia (AOR=2.09; 95% CI: 1.67-2.22). Patients taking calcium/vitamin D (AOR=2.98; 95% CI: 1.83-3.93), bisphosphonates (AOR=2.11; 95% CI: 1.26-2.61), or calcitonin (AOR=4.59; 95% CI: 3.40-5.77) were less likely to undergo repeat vertebral augmentation; however, those taking steroids (AOR=7.28; 95% CI: 6.32-8.08), acetaminophen (AOR=3.54; 95% CI: 2.75-4.83), or nonsteroidal anti-inflammatory drugs (NSAIDs) (AOR=6.14; 95% CI: 5.08-7.41) were more likely to undergo repeat vertebral augmentation. CONCLUSION: We conclude that the incidence of repeat vertebral augmentation is rather high. An understanding of risk factors predicting repeat vertebral augmentation provides valuable basis to improve health care for geriatric populations.

Pulsed radiofrequency treatment of articular branches of femoral and obturator nerves for chronic hip pain.

PURPOSE: Chronic hip pain is a common symptom experienced by many people. Often, surgery is not an option for patients with multiple comorbidities, and conventional drugs either have many side effects or are ineffective. Pulsed radiofrequency (PRF) is a new method in the treatment of pain. We attempt to compare the efficacy of PRF relative to conservative management for chronic hip pain. PATIENTS AND METHODS: Between August 2011 and July 2013, 29 patients with chronic hip pain were divided into two groups (PRF and conservative treatment) according to consent or refusal to undergo PRF procedure. Fifteen patients received PRF of the articular branches of the femoral and obturator nerves, and 14 patients received conservative treatment. Visual analog scale (VAS), Oxford hip scores (OHS), and pain medications were used for outcome measurement before treatment and at 1 week, 4 weeks, and 12 weeks after treatment. RESULTS: At 1 week, 4 weeks, and 12 weeks after treatment initiation, improvements in VAS were significantly greater with PRF. Improvements in OHS were significantly greater in the PRF group at 1 week, 4 weeks, and 12 weeks. Patients in the PRF group also used less pain medications. Eight subjects in the conservative treatment group switched to the PRF group after 12 weeks, and six of them had >50% improvement. CONCLUSION: When compared with conservative treatment, PRF of the articular branches of the femoral and obturator nerves offers greater pain relief for chronic hip pain and can augment physical functioning.

Increased risk of hip fractures in patients with dementia: a nationwide population-based study.

BACKGROUND: Dementia has been associated with an increased risk of hip fracture. However, little research has been conducted on the impact of dementia on wrist or vertebral fracture development. The aim of this study was to investigate whether dementia is a risk factor for different types of fracture in Taiwan. METHODS: The study sample was drawn from Taiwan's National Health Insurance Research Database of reimbursement claims, and comprised 1408 patients who visited ambulatory care centers or were hospitalized with a diagnosis of dementia. The comparison group consisted of 7040 randomly selected individuals. Cox proportional hazard regression model was used to examine associations between dementia and the risk of different types of fracture. RESULTS: During a 3-year follow-up period, 264 patients with dementia (18.75%) and 1098 patients without dementia (15.60%) developed fractures. Dementia was independently associated with increased risk of hip fracture [adjusted hazard ratio (HR) 1.92, 95% CI 1.48-2.49]. Patients with dementia and osteoporosis had the highest risk of developing hip fracture (adjusted HR 2.27, 95% CI 1.28-4.01). Dementia did not increase wrist fracture or vertebral fracture risk when compared to the control group, even in patients with osteoporosis. CONCLUSIONS: Individuals with dementia are at greater risk of developing hip fracture, particularly if they also have osteoporosis. Early mental screening programs and health education should be initiated to decrease disability and dependence in patients with dementia.

Modified fluoroscopy-guided sacroiliac joint injection: a technical report.

BACKGROUND AND OBJECTIVE: Sacroiliac joint (SIJ) injection can occasionally be challenging. We describe our experience in using conventional technique, and we developed an adjustment to overcome difficulties incurred. METHODS: Conventional technique required superimposition of the posterior and anterior SIJ lines. If this technique failed to provide entry into the joint, fluoroscopy was slightly adjusted to obtain an oblique view. RESULTS: Of 50 SIJ injections, 29 (58%; 44-72%) were successfully performed using conventional technique. In another 21 procedures, 18 (85.7%; 64-99%) were subsequently completed using oblique view technique. The medial joint line, viewed from this angle, corresponded to the posterior joint line in 17 cases. The lateral joint line corresponded to the posterior joint line in one case. CONCLUSIONS: Oblique view technique can improve the success rate of SIJ injection.