Electrical stimulation with polypyrrole-coated polycaprolactone/silk fibroin scaffold promotes sacral nerve regeneration by modulating macrophage polarisation.

Peripheral nerve injury poses a great threat to neurosurgery and limits the regenerative potential of sacral nerves in the neurogenic bladder. It remains unknown whether electrical stimulation can facilitate sacral nerve regeneration in addition to modulate bladder function. The objective of this study was to utilise electrical stimulation in sacra nerve crush injury with newly constructed electroconductive scaffold and explore the role of macrophages in electrical stimulation with crushed nerves. As a result, we generated a polypyrrole-coated polycaprolactone/silk fibroin scaffold through which we applied electrical stimulation. The electrical stimulation boosted nerve regeneration and polarised the macrophages towards the M2 phenotype. An in vitro test using bone marrow derived macrophages revealed that the pro-regenerative polarisation of M2 were significantly enhanced by electrical stimulation. Bioinformatics analysis showed that the expression of signal transducer and activator of transcriptions (STATs) was differentially regulated in a way that promoted M2-related genes expression. Our work indicated the feasibility of electricals stimulation used for sacral nerve regeneration and provided a firm demonstration of a pivotal role which macrophages played in electrical stimulation.

Advantages of robotic surgery for rectal cancer compared to laparoscopic surgery: pelvic anatomy and its impact on urinary dysfunction.

The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.

Incidence and Risk Factors of Sacral Fracture following Lumbosacral Fusion for Degenerative Spinal Stenosis with a Minimum Follow-up of 2 years: A Case-Control Study.

BACKGROUND: This study aimed to investigate the incidence and risk factors for sacral fractures following lumbosacral fusion. METHODS: We conducted a retrospective review of patients who underwent lumbosacral fusion for degenerative spinal stenosis with a minimum follow-up of 2 years. Patients who developed and those who did not develop a sacral fracture were categorized into the "sacral fracture" and "non-fracture" groups. The demographic and radiological data were compared between the two groups. RESULTS: A total of 65 patients were included in this study. Among them, seven patients were categorized into the sacral fracture and 58 patients into the non-fracture groups, respectively. The incidence of sacral fracture was 10.8%. In the sacral fracture group, age and fusion levels were significantly higher (P < 0.05), while bone mineral density (BMD) T-score was significantly lower (P < 0.05) than non-fracture group. PI, preoperative PT, postoperative SS, and postoperative LL were significantly higher (P < 0.05) in the sacral fracture than the non-fracture group. Multivariable logistic regression analysis showed that BMD T-score (Odds ratio [OR] 0.25, 95% confidence interval [CI] 0.08-0.79, P = 0.019), postoperative SS (OR 1.14, 95% CI 1.00-1.29, P = 0.047), and changes in L4-S1 lordosis (OR 1.11, 95% CI 1.00-1.23, P = 0.049) were significant factors. CONCLUSIONS: The overall incidence of sacral fracture was 10.8%. In our study, advanced age, low BMD, long fusion levels, and preoperative compensatory pelvic retroversion and excessive correction of it were risk factors for sacral fractures.

Perfecting the pour: A novel co-axial technique with sequential injections for optimising cement delivery during sacroplasty.

BACKGROUND: Percutaneous sacroplasty is an effective treatment for painful sacral fractures and tumours, however there is no accepted optimal technique for performing this procedure. This study investigated a novel approach to sacroplasty combining co-axial sacral access, sequential cement injections and hypothermic cement manipulation to improve cement delivery. METHODS: This retrospective study analysed 11 patients who underwent co-axial sacroplasty between April 2023 and March 2024 for treatment of painful insufficiency fractures (n = 5) or malignant sacral tumours (n = 6). All cases were performed using biplane fluoroscopy with conebeam CT navigation for planning and monitoring percutaneous access. Procedural details, technical outcomes, and clinical outcomes including Numerical Rating Scale (NRS) pain and analgesic utilisation on a six-point scale were analysed pre-procedure and at follow-up. RESULTS: Technical success of was achieved in all cases using this technique. The mean injected cement volume was 20.5 ± 6.4 ml. Median pre-procedural NRS pain scores of 8 (IQR 7.25-8) significantly decreased to 0 (IQR, 0-0.25) at follow-up (p <.01). The median preprocedural analgesic utilisation score reduced from 3 (IQR, 2-3) to 0 (IQR, 0-2.5) at follow-up (p <.01). Cement leakage occurred during two cases without associated adverse clinical sequelae. There were no major adverse events. CONCLUSION: Co-axial sequential injection sacroplasty is a safe and effective technique which allows facilitates controlled delivery of cement. Improved control of cement delivery, including around high-risk structures for cement leakage, offers a potential safety advantage over conventional sacroplasty techniques. Further research comparing technical and clinical outcomes to conventional techniques is warranted.

A Case of Sacral Osteomyelitis Causing Ascending Spinal Canal Infection.

Sacral osteomyelitis is an infection of the bone that extends posterior to the pelvis at the base of the spine. This condition typically occurs in elderly or bedbound/immobile patients and is treated with wound debridement, wound care, surgery, and antibiotic therapy. In this report, a case is presented of a rare complication of sacral osteomyelitis where the infection extended through the bone into the spinal canal causing an ascending spinal canal infection. This report is meant to provide an individual example of this rare complication which can hopefully be used to improve surveillance, treatment, and outcomes of this rare condition.

A new approach for percutaneous ilio-sacral screw fixation: CT-based pre-operative planning with conventional fluoroscopy to reduce malposition rate and operating time.

PURPOSE: Percutaneous ilio-sacral screw (ISS) insertion using conventional C-arm fluoroscopy has been a widely employed technique for pelvic posterior ring fixation, particularly in developing regions. However, this approach presents technical challenges, leading to a high malposition rate. We introduced a new method for ISS insertion without additional equipment or software and suggested whether it could reduce the malposition rate and operating time. METHODS: This is a retrospective cohort study. The study included all patients who underwent percutaneous ISS fixation between January 2020 and December 2022. Patients treated with open reduction or other types of implants were excluded. The patients were divided into 2 groups based on the screw insertion method: Group A utilized the traditional dual-plane adjustment method, while Group B received the newly introduced method. In all cases, conventional C-arm fluoroscopy was the sole guidance during the surgical procedure. Malposition rate, radiation exposure, and operating time were compared between groups. Post-operative CT scans were used to assess screw accuracy using the Smith grading method. The Student's t-test or the Mann-Whitney U test was chosen for comparing the quantitative variables based on the normality test results. The Chi-squared test was utilized for comparing qualitative variables. RESULTS: A total of 72 patients with pelvic posterior ring disruption treated with percutaneous ISS under conventional fluoroscopy guidance were included in this study. Among them, 32 patients were in Group A and 40 patients were in Group B. In Group B, the average operation duration per screw was 33 min with 29 fluoroscopy applications, which was significantly lower than that in Group A (44 min, p < 0.001, 38 times, p < 0.001, respectively). Furthermore, the post-operative CT scan revealed that only 10.7% (6/56) of screws in Group B were inappropriately positioned according to the Smith criteria. CONCLUSION: The novel method introduced in this study demonstrated a reduction in both malposition rates and operating time compared to the traditional dual-plane adjustment method. Precise pre-operative CT planning in conjunction with conventional fluoroscopy could establish this method as a widely applicable technique for percutaneous ISS fixation.

Optimizing sacral screw fixation in patients with caudal regression syndrome.

PURPOSE: The aim of this study is to evaluate and compare techniques and outcomes associated with two different technique of pelvic screw insertion in patients with caudal spine absence. METHODS: A cohort of patients with varying degrees of caudal structural regression, serves as the focal point of this investigation. Pelvic configurations were classified based on established criteria to facilitate comparative analysis. Each patient underwent spinal surgical interventions, with a follow-up period extending beyond 2 years. The primary surgical interventions predominantly involved spinal stabilization coupled with correction of scoliosis and kyphosis through one or two pairs of pelvic screws. RESULTS: In this study, we investigated a cohort of 22 patients with caudal spine absence, encompassing diverse conditions, such as lumbo-sacral aplasia, hemisacrum, and lumbar absence, with preserved sacrum. Following spinal surgery, notable improvements were observed in scoliosis and pathological lumbar kyphosis, with several patients achieving significant functional milestones such as independent ambulation. There were no significant differences in short-term complications between patients undergoing single versus double pair pelvic screw implantation. Long-term complications, primarily non-fusion, were notably more prevalent in patients undergoing fixation with a single pair of pelvic screws. CONCLUSION: Surgical intervention, particularly spinopelvic fixation, demonstrated promising outcomes in terms of improving spinal deformities. The implantation of two pairs of pelvic screws demonstrates greater reliability compared to the insertion of a single pair, diminishing the risk of non-fusion.

Bridging the spinal dysraphism spectrum between terminal myelocystocele and spinal cord lipoma: a report of two cases of true terminal lipomyelocystocele with holo-cord syrinx.

Terminal myelocystocele (TMC) is a rare form of spinal dysraphism which arises due to aberration in the secondary neurulation process involving the caudal cell mass. Terminal myelocystocele has been defined by Pang et al. based on essential and non-essential features. One of the non-essential features includes non dysraphic lipomas which do not tether to the neural placode. We are presenting two cases which meets all the essential criteria outlined by Pang et al. for TMC but also show the presence of a lipomatous component tethering to the neural placode, similar to a dysraphic lipoma. Through this article, we want to showcase a subset which represents "true" terminal lipomyelocystocele (TLMC), bridging the spectrum of spinal dysraphism between TMC and lipomyelomeningocele (LMM).

A New Rat Model of Sacral Cord Injury Producing a Neurogenic Bladder and Its Functional and Mechanistic Studies.

Sacral spinal cord injury (SSCI) can disrupt bladder neuromodulation and impair detrusor function. Current studies provide limited information on the histologic and genetic changes associated with SSCI-related neurogenic lower urinary tract dysfunction (NLUTD), resulting in few treatment options. This study aimed to establish a simple animal model of SSCI to better understand the disease progression. Ninety 8-week-old Sprague-Dawley (SD) rats were randomly separated into sham operation and SSCI groups. The SSCI group underwent sacral spinal cord injury, while the sham group did not. Urodynamic and histological assessments were conducted at various intervals (1, 2, 3, 4, and 6 weeks) post-injury to elucidate the disease process. Urodynamic examinations revealed significant bladder dysfunction in the SSCI group compared to the sham group, stabilizing around 3-4 weeks post-injury. Histological examination, including hematoxylin-eosin and Masson's trichrome staining, correlated these functional changes with bladder microstructural alterations. RNA-seq was performed on bladder tissues from the sham group and SSCI group at 6 weeks to identify differentially expressed genes and pathways. Selected genes were further analyzed using polymerase chain reaction (PCR). The findings indicated a pronounced inflammatory response in the first 2 weeks post-SSCI, progressing to bladder fibrosis at 3-4 weeks. In conclusion, this study presents a reliable, reproducible, and straightforward SSCI model, providing insights into bladder functional and morphological alterations post-SSCI and laying the groundwork for future therapeutic research.

The clinical value of ultrasound-guided sacral anesthesia in Intracavitary and/or interstitial brachytherapy for cervical Cancer.

OBJECTIVE: To explore the effectiveness and safety of ultrasound-guided sacral anesthesia in intracavitary and/or interstitial brachytherapy for cervical cancer patients. METHOD: A retrospective analysis was conducted on a total of 1039 intracavitary and/or interstitial brachytherapy involving 220 patients in our department from December 7, 2020 to March 21, 2024. The study assessed the satisfaction with anesthesia, changes in vital signs, onset time of anesthesia, dosage of anesthetic drugs, duration of anesthesia, and incidence of adverse reactions. RESULT: The rate of satisfaction with anesthesia was 73.8 %. There were no significant differences in patients' heart rate (HR), mean arterial pressure (MAP), systolic blood pressure (SBP), or oxygen saturation (SaO2) before and after anesthesia (P > 0.05). The onset time of anesthesia ranged from 20 to 35 min, the average dosage of anesthetic was 20 ml, and the duration of anesthesia lasted from 30 to 120 min. Serious adverse reactions included 2 cases of post-anesthesia syncope (associated with sacral cysts). The incidence of nausea was 2.2 %, and the total incidence of other adverse reactions, such as vomiting, urinary retention, bradycardia, anal discomfort, and dizziness, was less than 1 %. CONCLUSION: Ultrasound guided sacral anesthesia demonstrates significant advantages, including effective anesthesia, minimal impact on vital signs, rapid onset, prolonged maintenance, and a low incidence of adverse reactions. It is recommended for widespread application in intracavitary and/or interstitial brachytherapy for cervical cancer patients.

Embolization of an epidural arteriovenous fistula of the sacral nerve root with a neural tube defect: A case report.

INTRODUCTION AND IMPORTANCE: Rarely, epidural arteriovenous fistula (AVF) of the sacral neural root may be associated with neural tube defects. CASE PRESENTATION: A 46-year-old man presented with progressive weakness and numbness in both lower extremities. On physical examination, both lower extremities only had Grade III muscle strength. MRI revealed extensive dilated veins along the spinal cord, edema of the spinal cord, lipomyelomeningocele and tethering of the spinal cord. Angiography revealed an epidural AVF at the sacral neural root with intradural venous drainage. Endovascular treatment (EVT) was performed. First, a microcatheter accessed the AVF; then, another microcatheter coiled around the feeding artery near the fistula to establish the "pressure cooker" effect; finally, the AVF was obliterated by casting Onyx via the first microcatheter. After EVT, the patient's symptoms improved immediately. Postoperative computed tomography confirmed the presence of defective sacral bone. Based on the patient's physical examination and imaging findings, a neural tube defect with a tethered cord and a lipomyelomeningocele were confirmed. Two months later, the patient recovered well and could walk. The follow-up MR image revealed a nearly normal spinal cord. CLINICAL DISCUSSION: Microsurgical resection is difficult because of the deep location of such an AVF. EVT by casting Onyx can be a feasible option. To avoid Onyx reflux, the 'pressure cooker' technique can be helpful for obliterating such an AVF. CONCLUSION: On the basis of this case report, EVT can be effective for epidural AVFs of the sacral neural root in select cases.

Fever associated with machine activation after sacral neuromodulation: Case report.

INTRODUCTION AND IMPORTANCE: Sacral neuromodulation (SNM) is commonly used in the treatment of refractory overactive bladder (OAB), non-obstructive urinary retention (NOR) and fecal incontinence. Here, we report an atypical symptomatic case to enrich the limited international case series. CASE PRESENTATION: We report a case of a male patient with cauda equina nerve injury left over from a traumatic injury and dysfunction of urinary and fecal functions who, after undergoing phase I sacral nerve stimulator placement, developed fever when the machine was switched on, and the symptoms resolved when it was switched off. CLINICAL DISCUSSION: Sacral neuromodulation (SNM) is commonly used in the treatment of refractory overactive bladder (OAB), non-obstructive urinary retention (NOR) and fecal incontinence. The patient did not develop a non-infectious fever after the injury, only after the SNM device was installed and activated, and the temperature returned to normal after shutdown. We hypothesize that on top of the patient's pre-existing nerve damage and disorders, the activation of the SNM somehow stimulated the relevant sites, causing the patient to develop a neurogenic fever. CONCLUSION: We concluded that in this case, it is reasonable to consider that the patient's fever was closely related to the placement of the sacral nerve stimulator.

Feasibility and Safety of 3D-Navigated Trans-Sacral Bar Osteosynthesis for Fragility Fractures of the Sacrum: FIRST Clinical Experiences.

Background: There has been an increasing number of fragility fractures of the sacrum in the recent decade. With rates of up to 28%, the complication rates after surgical treatment are still at an unacceptably high level, and new treatment strategies are urgently needed. Therefore, the purpose of this study was to evaluate the potential of 3D-navigated trans-sacral bar osteosynthesis in the surgical treatment of fragility fractures of the sacrum. Methods: Retrospectively, from 2017 to 2023, all cases with confirmed fragility fractures of the sacrum in patients > 65 years of age that were surgically treated with navigated 3D-navigated trans-sacral bar osteosynthesis were included, and epidemiological data and the course of treatment analyzed in comparison to a matched control group. Results: Finally, 21 patients (18 women and 3 men) were included in this study. The average age of the patients was 82.6 (SD 6.3) in the intervention group and 79.4 (SD 6.7) in the control group. There were postoperatively detected complications in two cases (18%) in the intervention group and in four cases (40%, p = 0.362) in the control group. The postoperative in-hospital stay was 10 days (SD 3.8) vs. 11.4 days (SD 3.8) in the control. None of the patients in the intervention group and two in the control group needed revision surgery. Conclusions: Overall, 3D-navigated trans-sacral bar osteosynthesis seems to be a promising technique, enabling an accurate implant positioning while offering a low complication rate with an excellent short-term outcome in elderly patients with fragility fractures of the sacrum.

Origin of median sacral artery with fourth pair of lumbar artery - an alert for spine surgeons and interventionalists: A case report and mini literature review.

The median sacral artery (MSA) is the single unpaired dorsal branch of the abdominal aorta. The present case describes the relatively unusual origin of the median sacral artery in common with the fourth pair of lumbar arteries via a common trunk in a 74-year-old males' cadaver. Unusual common trunk is prone for iatrogenic injury in surgeries of the lumbar and pelvic region. Owing to the deep seated nature of MSA close to the periosteum of lumbar vertebrae and sacrum, detection of accidental rupture of MSA and ligation thereof becomes a difficult task. MSA is also increasingly being utilized for intra-arterial embolization of pelvic tumours. The proximal portion of the common origin may at times undergo cone shaped dilatation which is referred to as infundibulum or infundibular dilatation and can also transform into aneurysm later. Knowledge of this variation is imperative for spine and pelvic surgeons to avoid unwanted complications.

Outcomes of sacral neuromodulation in male patients with overactive bladder, chronic pelvic pain, and fecal incontinence.

INTRODUCTION: Despite the growing body of literature on sacral neuromodulation (SNM) outcomes, research focusing on male patients remains limited and often represented by small cohorts nested within a larger study of mostly women. Herein, we evaluated the outcomes of SNM in a male-only cohort with overactive bladder (OAB), fecal incontinence (FI), chronic bladder pain, and neurogenic lower urinary tract dysfunction (NLUTD). MATERIALS AND METHODS: This retrospective cohort study included 64 male patients who underwent SNM insertion between 2013 and 2021 at a high-volume tertiary center. Indications for SNM therapy included OAB, FI, chronic pelvic pain, and NLUTD. Descriptive statistics, Fisher's and t-test were used in analysis. RESULTS: The mean age was 57.7 ± 13.4 years, and the most frequent reason for SNM insertion was idiopathic OAB (72%), FI (16%), pelvic pain (11%), and NLUTD (11%). A majority (84%) of men received treatment prior to SNM insertion. 84% reported satisfaction and 92% symptom improvement within the first year, and these improvements persisted beyond 1 year in 73% of patients. Mean follow up was 52.7 ± 21.0 months. The complication rate was 23%, and the need for adjunct treatments was significantly reduced (73% to 27%, p < 0.001). Treatment outcomes did not differ significantly between various indications for SNM therapy or the presence of benign prostatic hyperplasia (BPH). CONCLUSION: SNM is an effective and safe procedure for male patients with neurogenic and non-neurogenic OAB, pelvic pain, and FI. Over 70% of patients experienced symptomatic improvement and remained satisfied in the mid to long term follow up. BPH does not seem to hinder treatment outcomes.

Use of computed tomography to evaluate pelvic canal in cats.

The objective of this study was to establish an evaluation technique for the feline pelvic cavity using computed tomography (CT). Client-owned cats with a normal pelvis (n = 50) or pelvic stenosis (n = 3) were included. We categorized pelvic CT images in the normal pelvis group into two types according to pelvic cavity shape, then calculated the sacral index (SI), pelvic canal area (PCA), and PCA/sacral width index (PSI). The reference intervals of these variables were determined based on the results in the normal pelvis group. In the normal pelvis group, the PSI, unlike the SI and PCA, was not affected by body weight. In addition to high intraobserver and interobserver reproducibilities, the PSI showed no significant differences according to pelvic cavity shape. However, the SI exhibited significant differences among pelvic cavity shapes. In the stenosis group, the postoperative PSI in all cats was within the reference interval. However, the postoperative SI in one case was lower than the reference interval. The PSI may become a new method for evaluation of the pelvic cavity, including the pelvic floor.

Long-term Outcomes of Sacral Nerve Stimulation on the Treatment of Fecal Incontinence: A Systematic Review.

INTRODUCTION: Sacral nerve stimulation (SNS) has now been used as a treatment for fecal incontinence (FI) for >20 years. The aim of this systematic review was to determine the long-term efficacy of SNS on the treatment of FI. MATERIALS AND METHODS: A comprehensive search of the MEDLINE, Embase, and Cochrane Central data bases was performed to find publications, excluding case reports, reporting outcomes of SNS treatment for FI in adults with ≥36 months of follow-up. Bias was assessed using the Risk of Bias in Non-randomized Studies-of Interventions tool. Data were summarized per reported FI-related outcomes for symptom severity and quality of life. RESULTS: In total, 3326 publications were identified, and 36 studies containing 3770 subjects were included. All studies had a serious risk of bias. Success was variably defined by each publication and ranged from 59.4% to 87.5% for per-protocol analyses and 20.9% to 87.5% for intention-to-treat analyses. All studies reporting bowel diary data, St Mark's scores, and Cleveland Clinic Incontinence Scores indicated significant improvement with SNS treatment in the long term. Studies that evaluated quality-of-life outcomes also all showed improvements in quality of life as measured by the Fecal Incontinence Quality of Life Scale. The aggregate revision rate was 35.2%, and the explantation rate was 19.7%. CONCLUSIONS: Improvements in objective and subjective outcomes at ≥36 months support using SNS for the long-term treatment of FI. Interpretation of these data is limited by a lack of comparative trials and heterogeneity of the included studies.

How to Prevent Local Recurrence of Sacral Chordoma Treated with Carbon-Ion Radiotherapy: An Analysis of the Risk Factors of Local Failure and an Adequate Disease Margin.

INTRODUCTION: Recent reports have described the usefulness of carbon ion radiotherapy (CIRT) for inoperable sacral chordomas. However, its long-term local control rate needs to be improved. The present study identified the risk factors that affect the local relapse of sacral chordomas and the appropriate margins from the tumors. METHODS: Forty-nine patients with sacral chordoma treated with CIRT between 2011 and 2022 were retrospectively analyzed. Factors predicting the risk of local recurrence were evaluated, including age, sex, tumor size, muscle invaded with tumor, and surgery before CIRT. To determine the appropriate margin, the distance between the clinical target volume (CTV) and the out-field recurrent lesions was analyzed. RESULTS: The patients included 37 males and 12 females with a mean age of 67.1 years. A multivariate analysis showed that a tumor size >8 cm and invasion into the gluteus maximus muscle were significant risk factors with hazard ratios of 5.56 and 15.20 (p = 0.02 and 0.01), respectively. Out-field recurrence occurred in 13 cases, with 6, 3, and 4 relapses occurring in the muscle, bone, and both, respectively. The tumor occurred within 20 mm from the CTV in 60% of relapses in the muscles. CONCLUSION: The current study presented novel findings on CIRT for sacral chordomas, although there were several limitations, such as a short follow-up period to investigate slow-growth tumors and a small number of tumor specimens owing to inoperative cases. A tumor size >8 cm and invasion into the gluteus maximus muscle were shown to be risk factors for recurrence in the treatment of sacral chordoma with CIRT. Our findings further suggest that an additional 2-cm margin from the CTV in the muscle fiber direction is recommended during CIRT.

Magnetic resonance imaging phantom-based S1 vertebral scores are indicators of fat-water-like osteoporotic changes in postmenopausal women: a pilot study.

STUDY DESIGN: A prospective study. PURPOSE: To assess fat-water-like tissue changes on the 1st sacral vertebra using novel magnetic resonance imaging (MRI) phantombased F- and W-scores and evaluate their diagnostic performances in osteoporosis detection. OVERVIEW OF LITERATURE: Using an uncommonly advanced MRI technique, previous studies have found that fat-water changes were consistent with osteoporosis. The role of routine MRI sequences can be extended in this regard. The S1 vertebra is considered a crucial anatomical site in spine surgeries because it seldom suffers from fractures. Thus, S1 could indicate osteoporotic fat-water changes. METHODS: Forty-two female volunteers (aged 62.3±6.3 years) underwent spine examination with both MRI (including a phantom) and dual-energy X-ray absorptiometry (DXA) following ethical approval. MRI phantom-based F- and W-scoreS1 were defined by normalizing S1 vertebral signal intensities (SIs) by coconut oil and water SIs of the phantom on T1- and T2-weighted imaging, respectively. Using receiver operating characteristic analysis, the diagnostic performances of the new scores for evaluating osteoporosis and vertebral fractures were investigated against standard areal bone mineral density measured with DXA (DXA-aBMD). RESULTS: The F-scoreS1 and W-scoreS1 were greater (4.11 and 2.43, respectively) in patients with osteoporosis than those without osteoporosis (3.25 and 1.92, respectively) and achieved areas under the curve (AUCs) of 0.82 and 0.76 (p<0.05), respectively, for osteoporosis detection. Similarly, the mean F-scoreS1 and W-scoreS1 were higher (4.11 and 2.63, respectively) in patients with vertebral fractures than in those without fractures (3.30 and 1.82, respectively) and had greater AUCs (0.90 for W-scoreS1 and 0.74 for F-scoreS1) than DXA-aBMD (AUC, 0.26; p<0.03). In addition, the F- and W-scoreS1 demonstrated a strong correlation (r=0.65, p<0.001). CONCLUSIONS: The new S1 vertebral-based MRI scores were developed to detect osteoporotic changes and demonstrated improvements over DXA-aBMD in differentiating patients with vertebral fractures.

Third-Line Therapeutic Interventions for Non-Neurogenic Bladder Dysfunction in Children.

PURPOSE OF REVIEW: The aim of this article is to review considerations and efficacy of third-line treatments for pediatric non-neurogenic bladder dysfunction, including Botulinum toxin A (BoTNA), Posterior Tibial Nerve Stimulation (PTNS), and Sacral Neuromodulation (SNM). RECENT FINDINGS: Federal Drug Administration approval for use of beta-3-agonists in overactive detrusor activity in pediatric patients may provide an additional step prior to third-line therapies. New long-term data on pediatric SNM efficacy, complications, and revision rates will provide valuable information for counseling families. BoTNA offers a safe and efficacious treatment to decrease detrusor contractility and improve bladder capacity but is limited by the half-life of BoNTA agent. Percutaneous or transcutaneous PTNS offers improved voided volumes or cure in some patients but is time-intensive. SNM can be utilized in a variety of LUTD pathology with high success rate and cure but should consider cumulative anesthetic and fluoroscopic exposures for battery replacements and re-positioning for patient growth.