A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study.

STUDY DESIGN: Prospective Study. OBJECTIVES: There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons. METHODS: This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group. RESULTS: Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches. CONCLUSION: Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

Clinicoradiological Risk Factors Associated with Inability to Achieve Minimum Clinically Important Difference in Operated Cases of Cervical Spondylotic Myelopathy.

STUDY DESIGN: This is a retrospective cohort study. PURPOSE: This study aimed to identify the clinicoradiological risk factors associated with the inability to achieve minimum clinically important difference (MCID) on the modified Japanese Orthopaedic Association (mJOA) Scale in operated cases of cervical spondylotic myelopathy (CSM). OVERVIEW OF LITERATURE: Only a few studies have evaluated the outcomes of surgery performed for CSM using MCID on the mJOA scale. METHODS: We analyzed 124 operated CSM cases from March 2019 to April 2021 for preoperative clinical features, cervical sagittal radiographic parameters, and magnetic resonance imaging (MRI) signal intensities (SI). The risk factors associated with missing the MCID (poor outcome) on mJOA at the final follow-up were identified using binary logistic regression. Multivariate analysis was used to find significant risk factors, and odds ratios (OR) were computed. RESULTS: A total of 110 men (89.2%) and 14 women (10.8%) with an average age of 53.5±13.2 years were included in the analysis. During the last follow-up, 89 cases (72.1%) achieved MCID (meaningful gains following surgery) while 35 (27.9%) could not. The final model identified the following parameters as significant risk factors for poor outcome: increased duration of symptoms (OR, 6.77; p=0.001), lower preoperative mJOA scale (OR, 0.75; p=0.029), the presence of multilevel T2-weighted (T2W) MRI SI (OR, 4.79; p=0.004), and larger change in cervical sagittal vertical axis (ΔcSVA) (OR, 1.06; p=0.013). Also, an increase in cSVA postoperatively correlated with a reduced functional recovery rate (r=-0.4, p<0.001). CONCLUSIONS: Surgery for CSM leads to significant functional benefits. However, poorer outcomes are observed in cases of greater duration of symptoms, higher preoperative severity with multilevel T2W MRI SI, and a larger increase in the postoperative cSVA (sagittal imbalance).

Influence of Preoperative Sagittal Alignment on Functional Recovery in Operated Cases of Cervical Spondylotic Myelopathy.

Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated. Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0-10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed. Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11-50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; -11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery ( p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant. Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome.

Development of Tuberculosis Spine Instability Score (TSIS): An Evidence-Based and Expert Consensus-Based Content Validation Study Among Spine Surgeons.

STUDY DESIGN: An expert-panel consensus-based content validation and case-based clinical validation study. OBJECTIVE: To develop a novel scoring system for diagnosing instability in tuberculosis (TB) spine using an expert-panel consensus followed by clinical validation for validating the content. SUMMARY OF BACKGROUND DATA: Currently, diagnosis of instability is primarily experience-based which may lead to considerable variability and misdiagnosis in the hands of a relatively in-experienced spine surgeon. Considering the potential complications this entity entails, a universally accepted scoring criteria is very important for accurate and uniform diagnosis of instability in TB spine. METHODS: The development of TB spine instability score (TSIS) followed a two-step process, one designing the instrument and the other obtaining judgemental evidence. For judgemental evidence a panel of experts was appointed to make appropriate modifications and content validation for finalizing the scoring instrument. This score was applied on 30 patients of TB spine and receiver operating characteristic (ROC) curves were drawn for sensitivity and specificity analysis. RESULTS: The comprehensive scoring criteria to diagnose instability in TB spine was approved after three rounds of expert panel discussions with an index of content validation more than 0.75 after final round of panel discussion. On case-based validation after plotting ROC curves, sensitivity and specificity for diagnosing stable and potentially unstable lesions at a cut-off score of 6 was 92.9% and 86.8% respectively whereas for diagnosing potentially unstable and unstable lesions at a cut-off score of 10 was 94.3% and 81.9%, respectively. CONCLUSION: TSIS is a comprehensive scoring system integrating demographic, anatomical, clinical, and radiological factors aimed at diagnosing instability in TB spine. The classification determines indications for surgical stabilization in patients with TB spine, with no or little neurological deficit.Level of Evidence: 4.

Morphometric parameters of the odontoid process of C2 vertebrae, in Indian population, a CT evaluation.

BACKGROUND: Osteosynthesis of odontoid fractures, especially for type II odontoid fractures, is often achieved by the placement of screws. Here, utilizing CT, we evaluated the normal anatomy of the odontoid process in an Indian population to determine whether one or two screws could be anatomically accommodated to achieve fixation. METHODS: CT-based morphometric parameters of the odontoid process were assessed in 200 normal Indian patients (2018-2020). RESULTS: Of 200 patients, 127 were male, and 73 were female. The mean minimum external transverse diameter (METD) was 8.80 mm (range 6.1-11.9 mm). Six (3%) patients had a minimum internal transverse diameter (TD) of >8.0 mm that would allow for the insertion of two 3.5-mm cortical screws without tapping, while 10 (5%) patients had TDs of <7.4 mm; none had diameters of <5.5 mm. The mean length of the implant was 36.45 mm in females and 36.89 mm in males, and the mean angle of screw insertion was 60.34° in females and 60.53° in males. CONCLUSION: About two-thirds (59%) of the 200 subjects in our study had a METD of <9 mm, indicating the impracticality for introducing second screws for odontoid fixation.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Retrospective Study.

OBJECTIVES: Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the perioperative factors, outcomes, and complications of each procedure and compare among them with 946 patients contributed by 10 centers and operated by experienced surgeons. METHODS: This was a retrospective study of patients operated using open discectomy, microdiscectomy, microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques with a follow-up of minimum 2 years. The inclusion criteria were age >18 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level. RESULTS: There was a significant improvement in the visual analog scale score of back, leg, and Oswestry Disability Index scores postoperatively across the board, with no significant difference between them. Minimally invasive procedures (microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) had shorter operation time, hospital stay, better cosmesis, and decreased blood loss compared with open procedures (open discectomy and microdiscectomy). The overall complication rate was 10.1%. The most common complication was recurrence (6.86%), followed by reoperation (4.3%), cerebrospinal fluid leak (2.24%), wrong level surgery (0.74%), superficial infection (0.62%), and deep infection (0.37%). There were minor differences in incidence of complications between techniques. CONCLUSION: Although minimally invasive techniques have some advantages over the open techniques in the perioperative factors, all the techniques are effective and provide similar pain relief and functional outcomes at the end of 2 years. The various rates of individual complications provide a reference value for future studies.

Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature.

BACKGROUND: Intraoperative anteropulsion of a transforaminal lumbar interbody fusion (TLIF) cage is infrequent but may have disastrous complications. Here, we present an 80-year-old female whose L5-S1 TLIF cage extruded anteriorly and later migrated into the pouch of Douglas (i.e. an anterior peritoneal reflection between the uterus and the rectum) posing potential significant risks/complications, particularly of a major vessel injury. Notably, this 80-year-old patient with degenerative lumbosacral scoliosis should have only undergone a lumbar decompression alone. CASE DESCRIPTION: An 80-year-old female underwent a two-level L4-L5 and L5-S1 TLIF to address lumbosacral canal stenosis with degenerative scoliosis. During the L5-S1 TLIF, intraoperative fluoroscopy showed the anterior displacement of the cage ventral to the sacrum. As she remained hemodynamically stable, the cage was left in place. The postoperative CT scan confirmed that the cage was located in the retroperitoneum but did not jeopardize the major vascular structures. Three months later, however, the cage migrated inferiorly into the pouch of Douglas. Although asymptomatic, general surgery and gynecology advised laparoscopic removal of the cage to avoid the potential for a major vessel/bowel perforation. However, the patient refused further surgery, and 3 years later remained asymptomatic. CONCLUSION: Anterior cage migration following TLIF has been rarely reported. In this case, an L5-S1 TLIF cage extruded anteriorly in an 80-year-old severely osteoporotic female and migrated 3 months later into the pouch of Douglas, posing the risk of a major vessel/bowel injury. Although surgical removal was recommended, the patient refused further surgery but remained asymptomatic 3 years later. Notably, the authors, in retrospect, recognized that choosing to perform a 2-level TLIF in an 80-year-old female reflected poor judgment.

Misdiagnosis of "White Cord Syndrome" following posterior cervical surgery for ossification of the posterior longitudinal ligament: A case report.

BACKGROUND: Following decompressive cervical surgery for significant spinal cord compression/myelopathy, patients may rarely develop the "White Cord Syndrome (WCS)." This acute postoperative reperfusion injury is characterized on T2W MRI images by an increased intramedullary cord signal. However, it is a diagnosis of exclusion, and WCS can only be invoked once all other etiologies for cord injury have been ruled out. CASE DESCRIPTION: A 49-year-old male, 3 days following a C3-C7 cervical laminectomy and C2-T1 fusion for extensive cord compression due to ossification of the posterior longitudinal ligament (OPLL), developed acute quadriparesis. This new deficit should have been attributed to an intraoperative iatrogenic cord injury, not the WCS. CONCLUSION: Very rarely patients sustain postoperative significant/severe new neurological deficits attributable to the WCS. Notably, the WCS is a diagnosis of exclusion, and all other etiologies (i.e. intraoperative iatrogenic surgeon-based mechanical cord injury, graft/instrumentation extrusion, failure to adequately remove/resect OPLL thus stretching cord over residual disease, other reasons for continued cord compression, including the need for secondary surgery, etc.) of cord injury must first be ruled out.

Incidental unintentional breakage of epidural catheter in supralaminar area: A case report.

BACKGROUND: Among some of the known complications, breakage of epidural catheter, though is extremely rare, is a well-established entity. Visualization of retained catheter is difficult even with current radiological imaging techniques, and active surgical intervention might be necessary for removal of catheter fragment. We report such a case of breakage of an epidural catheter during its insertion which led to surgical intervention. CASE DESCRIPTION: A 52-year-old, an 18G radiopaque epidural catheter was inserted through an 18G Tuohy needle into the epidural space at T8-T9 interspace in left lateral position. Resistance was encountered. While the catheter was being removed with gentle traction along with Tuohy needle, it sheared off at 12 cm mark. After informing the operating surgeon and the patient, immediately an magnetic resonance imaging and computed tomography (CT) scan were done. CT scan with sagittal and coronal reconstruction was done. Epidural catheter was visualized at D9 lamina-spinous process junction who was removed by surgical intervention. CONCLUSION: Leaving of epidural catheter puts the anesthetist in a dilemma. To evade such an event, it is important to stick to the traditional guiding principle for epidural insertion and removal. In spite of safety measures, if event occurs, the patient should be informed about it. Surgery is reserved for symptomatic patients or asymptomatic patients to avoid future complications.

A Case Series of Acute Painless Bilateral Foot Drop Without Cauda Equina Syndrome.

Introduction: Acute painless bilateral foot drop without bowel/bladder involvement is a very rare presentation of lumbar degenerative disorders. Only a few cases have been published on it in the literature. An early intervention could prove to be very helpful for the neurological recovery. Case Report: We present three cases where patients developed acute onset bilateral foot drop without radiculopathy and without bowel/bladder involvement. The first case was due to acute lumbar disc herniation, the second was caused by acute disc prolapse in a pre-existing asymptomatic lumbar canal stenosis, and the third one precipitated in a progressive degenerative severe lumbar spinal stenosis. Two cases (case reports 1 and 3) underwent minimal invasive decompression while the other case (case report 2) underwent instrumentation+ decompression + fusion. Case 1 and 2 with a short duration of symptoms showed good neurological recovery, whileereas Case 3 with longer duration of complaints did not improve. Conclusion: Patients presenting with painless bilateral foot drop without cauda equine syndrome should be evaluated for spinal causes besides central nervous systemCNS, peripheral nerve, metabolic and autoimmune causes. Any finding in support of lumbar degenerative disease as the cause after excluding other causes should prompt for surgical decompression of the spine as an early intervention might help patient recover back to a normal and active lifestyle.

Tophaceous gout in thoracic spine mimicking meningioma: A case report and literature review.

BACKGROUND: Gout is a common metabolic disorder of purine metabolism, causing arthritis in the distal joints of the appendicular skeleton. Spine involvement is rare, and very few cases of spinal gout have been reported. The authors present a rare case of axial gout with tophaceous deposits in the thoracic spinal canal resulting in cord compression and mimicking a meningioma. CASE DESCRIPTION: A 33-year-old male presented with chronic mid back pain and a progressive paraparesis. The presumed diagnosis was meningioma based on MR imaging with/without contrast that showed a posterolateral, right-sided, and T10-T11 intradural extramedullary lesion. Notable, was hyperuricemia found on hematological studies. The patient underwent a decompressive laminectomy (T9-T11) for excision of the lesion, intraoperatively, an intraspinal, chalky, white mass firmly adherent to and compressing the dural sac was removed. The histopathology confirmed the diagnosis of a gouty tophus. Postoperatively, the patient's pain resolved, and he regained the ability to walk. CONCLUSION: A gouty tophus should be included among the differential diagnostic considerations when patients with known hyperuricemia present with back pain, and paraparesis attributed to an MR documented compressive spinal lesion.

Traumatic posterior dislocation of sacrococcygeal joint: A case report and review of the literature.

BACKGROUND: Sacrococcygeal joint dislocation is very rare. There are seven cases of sacrococcygeal joint dislocation found in the literature; most are anterior, and only one prior case of posterior dislocation was reported involving the mid-coccygeal joint. Here, we report another case of posterior dislocation of the sacrococcygeal joint. CASE DESCRIPTION: A 19 year-old female developed acute low-back and groin pain following a fall from the first floor. She was diagnosed with an unstable pelvic fracture along with posterior dislocation of the sacrococcygeal joint. The next day, after being hemodynamically stabilized, she underwent percutaneous fixation of the sacral fracture, while the sacrococcygeal joint dislocation was managed conservatively. Her pain decreased, and she was discharged on the third postoperative day and followed up to 6 weeks. CONCLUSION: Most sacrococcygeal joint dislocations can be managed conservatively.

Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature.

BACKGROUND: The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4-L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management). CASE DESCRIPTION: A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4-L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4-L5 level. This was treated with a L4-L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection. CONCLUSION: Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.

Progressive dysphagia and dysphonia secondary to DISH-related anterior cervical osteophytes: A case report.

BACKGROUND: Dysphagia due to diffuse idiopathic skeletal hyperostosis (DISH)-related anterior cervical osteophytes is not uncommon. However, this rarely leads to dysphonia and/or dysphagia along with life- threatening airway obstruction requiring emergency tracheotomy. CASE DESCRIPTION: A 56-year-old male presented with progressive dysphagia and dysphonia secondary to DISH-related anterior osteophytes at the C3-C4 and C4-C5 levels. The barium swallow, X-ray, magnetic resonance imaging, and computed tomography scans confirmed the presence of DISH. Utilizing an anterior cervical approach, a large beak-like osteophyte was successfully removed, while preserving the anterior annulus. After clinic-radiological improvement, the patient was discharged with a soft cervical collar and nonsteroidal anti-inflammatory drug (NSAID). CONCLUSION: Large anterior osteophytes in Forestier disease/DISH may cause dysphagia and dysphonia. Direct anterior resection of these lesions yields excellent results as long as other etiologies for such symptoms have been ruled out.

Stenotrophomonas maltophilia spondylodiscitis following lumbar microdiscectomy mimicking a cotton granuloma: A case report and literature review.

BACKGROUND: Vertebral osteomyelitis caused by Stenotrophomonas maltophilia is very rare. There are only two cases reported in literature. Here, we present a 48-year-old immunocompetent male who, following a lumbar microdiscectomy, developed postoperative spondylodiscitis due to S. maltophilia that mimicked a cotton granuloma. CASE REPORT: Two months ago, a 48-year-old male underwent a lumbar L4-L5 microdiscectomy, he newly presented with the left thigh and leg pain of 4 weeks duration. Laboratory studies revealed a CRP of 26 mg/l, an ESR of 6 mm (1st h), and total leukocyte count of 7.85 thousand/ul. The MRI T2 images showed a focal hyperintense lesion in the left lateral recesses at the L4-L5 level; the accompanying hypointense-smooth margin resembled a cotton granuloma. At surgery, we found a localized epidural collection of pus; S. maltophilia was isolated from the culture. His symptoms gradually improved, and symptoms fully resolved with 3 months of subsequent antibiotic therapy. CONCLUSION: S. maltophilia causing vertebral osteomyelitis is extremely rare and can sometimes mimic a cotton granuloma. MR diagnosis, surgical decompression, and obtaining cultures are requisite to direct appropriate antibiotic therapy.

Lumbar Canal Stenosis: A Prospective Clinicoradiologic Analysis.

BACKGROUND: Although spinal canal narrowing is thought to be the defining feature for the clinical diagnosis of lumbar canal stenosis, the degree of spinal canal stenosis necessary to elicit neurologic symptoms is not clear. Several studies have been performed to detect an association between a narrow spinal canal and clinical symptoms. Through our prospective study, we compared the radiologic criteria with the clinical criteria using the Oswestry Disability Index (ODI) and assessed how they correlate. MATERIALS AND METHODS: We used the qualitative grading (morphological classification system on magnetic resonance imaging [MRI]) system, dural sac cross-sectional area (DSCA), and sedimentation sign on MRI images and compared them with the Self-Paced Walking Ability (Self-Paced Walking Test) and ODI of the patients in the study. The systems were applied to 85 patients divided into three groups: group A: 43 patients with neurogenic claudication and able to walk < 30 minutes; group B: 11 patients with neurogenic claudication and able to walk > 30 minutes; and group C: 31 patients with simple back pain and no signs of neurologic claudication. RESULTS: The mean ODI was 21.19 in group C, 46.50 in group B, and 61.95 in group A. The difference was statistically significant. The mean DSCA was 164.42 mm2 in group C, 49.94 mm2 in group B, and 35.07 mm2 in group A. The difference was statistically significant. The sedimentation sign was negative in 96.8% patients in group C, 54.5% patients in group B, and 32.6% patients in group A. The difference was statistically significant. Group C had 9.3% patients in morphology grade A3, 51.6% in grade A2, and 38.7% patients in grade A1. Group B had 63.6% patients in grade C, 18.2% patients in grade B, 9.1% in grade A4, and 9.1% in grade A3. Group A had 18.6% patients in grade D, 39.5% in grade C, 27.9% in grade B, 11.6% in grade A4, and 2.3% in grade A3. The mean DSCA of group C was significantly different from group A and group B, but the difference of the mean DSCA between group A and group B was not statistically significant. The relationship of ODI to DSCA, ODI to sedimentation sign, and ODI to morphological grading for group C and group A was not statistically significant. The relationship of morphological grading to DSCA was statistically significant for all three groups. CONCLUSION: DSCA, morphological grading, and sedimentation sign are good to excellent radiologic indicators differentiating patients with simple back pain from those with lumbar spinal stenosis. Clinically, ODI is an excellent indicator of the severity of stenosis. But ODI statistically has no significant correlation to any of these radiologic parameters.

Congenital absence of a lumbosacral facet joint: A case report.

BACKGROUND: Congenital absence of the lumbosacral facet joint is extremely rare, with only 26 cases reported in the literature. Here, we present a patient with the unilateral absence of the left fifth lumbar inferior articular process and reviewed the relevant literature. CASE DESCRIPTION: A 32-year-old gentleman, who had undergone right L4-5 lumbar microdiscectomy 3 months ago now presented with acute low back and left leg pain following a fall. He is now presented with acute low back and left leg pain following a fall. Plain radiographs of the L-S spine revealed an absent left L5-S1 zygapophyseal joint. The magnetic resonance imaging and computed tomography studies additionally confirmed an absent unilateral left L5 lumbar inferior articular process. CONCLUSION: Patients presenting for lumbar surgery may have unilaterally absent lumbosacral zygapophyseal joints, which may impact the outcome of surgical treatment.

Thoracic cryptococcal osteomyelitis mimicking tuberculosis: A case report.

BACKGROUND: Isolated cryptococcal osteomyelitis of the spine is extremely uncommon; there have been only seven cases identified in literature. The majority were originally misdiagnosed as tuberculosis. Here, we present a patient with cryptococcal osteomyelitis of the thoracic spine with associated fungal retinal deposits. CASE DESCRIPTION: A 45-year-old, type II diabetic female presented with a 5-month history of severe back pain. Her magnetic resonance imaging (MRI) revealed osteomyelitis involving the T4 vertebral body with epidural and prevertebral extension; notably, the intervertebral disc spaces were not involved. Although the fine-needle aspiration cytologic examination was inconclusive, the patient was empirically placed on antitubercular drug therapy. One month later, she became fully paraplegic. The MRI now demonstrated osteolytic lesions involving the T4 vertebral body with cord compression. She underwent biopsy of the T4 vertebral body and a transfacet T4 decompression with T2-T6 pedicle screw fixation. Culture and histopathological examinations both documented a cryptococcal infection, and she was placed on appropriate antifungal therapy. Notably, 3 weeks after surgery, she developed a sudden loss of vision loss due to retinal fungal endophthalmitis. She recovered vision in one eye after the administration of intravitreal voriconazole but lost vision in the other eye despite a vitrectomy. Over the next 8 months, she gradually recovered with motor function of 4/5 in both lower extremities without evidence of recurrent disease. CONCLUSION: Cryptococcal infection should be among the differential diagnostic considerations for patients with vertebral osteomyelitis. Notably, diagnostic delay can lead to devastating neurological deficits and involvement of other organ systems.

Fluoroscopy Guided Percutaneous Transpedicular Biopsy of Vertebral Body Lesion.

BACKGROUND: The common causes of vertebral body lesion are metastasis, infection, primary malignancies or osteoporotic fractures. Histopathological examination is necessary to confirm the diagnosis. There are different approaches to collect the biopsy samples and they have different adequacy and accuracy rates and also possible complications. This study aims to determine adequacy, accuracy and safety of the fluoroscopy guided percutaneous transpedicular biopsy of the vertebral body lesion. METHODS: This is retrospective review of all the patients who underwent fluoroscopy guided percutaneous transpedicular biopsy from January 2013 to October 2016. We reviewed medical records and biopsy reports, plain radiographs, Computed Tomography Scan and Magnetic Resonance Imaging and additional necessary investigations required to confirm the diagnosis. RESULTS: Fifty two patients underwent fluoroscopy guided percutaneous transpedicular biopsy of vertebral body lesion in 55 different levels. Thirty six patients were male and 16 were female with mean age of 54.17 years (range 2-87 years). This procedure was performed in 55 levels from D3 to S1. The adequate sample was retrieved from 50 samples in 47 cases (90.9%). The diagnosis was confirmed by histopathological examination from41 samples in 38 cases (82%). In three cases the histopathology was inconclusive but microbiological investigation of tissue sample confirmed the diagnosis. So in total 44 samples from 41 cases (80%), the diagnosis was confirmed by the procedure. We did not encounter any complications during the procedure. CONCLUSIONS: Fluoroscopy guided percutaneous transpedicular biopsy is a safe minimally invasive procedure with high adequacy and accuracy rate.

Dual beam modulated magneto-optical measurement setup.

A dual beam magneto-optical setup employing a dual axis photoelastic modulator (PEM) and an intensity-stabilized laser was designed and constructed. The beam transmitted through or reflected of the sample is split by a Wollaston prism into two orthogonal high-quality linearly polarized beams. Two photodetectors are used to measure the DC and 2ω components of each beam's intensity. Theoretical calculations using Jones matrices show that the difference between the 2ω signals, i.e., ΔI2ω, is linearly proportional to the Kerr or Faraday rotation of the sample. Different from I2ω of a traditional single beam setup, the ΔI2ω does not contain an offset caused by the Fabry Perot interference in the PEM's optical head, making the setup less sensitive for small sample movements and laser drifts including intensity, wavelength, and beam direction drifts all originating from mainly temperature fluctuations in the lab.