An incidental migrating intra-spinal bullet: the silent victim of celebratory gunfire.

BACKGROUND: Incidentally found intra-spinal bullets are extremely rare, and have never been reported in the literature. The aim of this study is to report a rare case of an asymptomatic migrating intra-spinal bullet, emphasizing the role of cultural context in history taking, and describing its surgical retrieval technique. CASE PRESENTATION: We discuss a case of a 10-years old boy with an incidentally discovered intra-spinal bullet opposite to the L5 vertebral level, who presented 3 months after the suspected initial insult. Following its migration to the L3/L4 level intraoperatively, the bullet was forced to spontaneously return to its preoperative position by reverse Trendelenburg Position, Valsalva maneuver and Intrathecal saline infusion, thus avoiding extending the previously performed laminectomy. CONCLUSION: The authors remind the readers that history is the cornerstone of the clinical practice, even in the most obscure cases. Many convoluted intra-operative situations could be resolved by utilizing basic anatomical and physiological principles.

Musculoskeletal pain among medical students at two Jordanian universities.

BACKGROUND: Musculoskeletal (MSK) pain is a debilitating multi-perceptual condition afflicting many individuals, especially individuals in the medical profession. OBJECTIVE: To analyze and evaluate the prevalence of musculoskeletal pain among medical students at Jordanian universities during the complete virtual learning process. METHODS: A cross-sectional study of 593 medical students at two Jordanian universities was conducted. A modified Nordic questionnaire was used to assess musculoskeletal pain in three body regions. RESULTS: Five hundred ninety-three students at the two Jordanian universities participated in this study. The prevalence of having MSK pain during the past week in the neck, shoulder, and lower back was 34.6%, 27%, and 41%, respectively; during the past 12 months, it was 61.2%, 45.5%, and 63.1%, respectively. Overall prevalence of having MSK pain was 58.9% in the last week and 78.1% in the past 12 months. 66.8% of students who had psychosomatic symptoms and 62.3% of those with depressive symptoms in the past week had MSK pain. Students who studied 8 hours per day had higher percentages of MSK pain (68.4%) (OR 1.12, 95% CI 0.965-1.312). The average number of hours using a computer per day was significantly associated with MSK pain (p= 0.032). MSK pain during the last week was significantly associated with psychosomatic symptoms (OR 1.842, 95% CI 1.272-2.668, p= 0.001). Family history of MSK pain was significantly related to the presence of the problem in participants (OR 1.732, 95% CI 1.182-2.538, p= 0.005). Gender, depressive symptoms, average hours of computer use per day, and average hours of study at home per day did not show significant relationships with MSK pain over the year. CONCLUSIONS: High prevalence of MSK pain was observed among medical students. Measures to balance in-person and virtual learning should be considered in medical schools to minimize the risk of MSK pain.

Management of a rare case of isolated U-shaped displaced sacral fracture in a young female high school student.

Sacral fractures in young healthy patients are usually linked to high-energy trauma. They are often associated with multiple other injuries. Isolated sacral fractures are rare and can be easily missed in the absence of other surrounding pelvic or spinal injuries. In this article, we present a rare case of isolated U-shaped displaced sacral fracture despite the high-energy mechanism of injury being missed on initial presentation. This is a 17-year-old healthy female who presented to the emergency department after falling from five-meter height. She complained of lower back pain and inability to ambulate. Physical examination revealed significant sacral tenderness, bilateral lower limb weakness and hypoesthesia, anesthesia of the saddle area, weak anal tone and absent anal reflex. Initial radiographs showed no apparent fractures. Further imaging by pelvic computed tomography, however, revealed an isolated U-shaped displaced sacral fracture. The patient was treated by decompression and lumbopelvic fixation by triangular osteosynthesis and iliosacral screw. This fixation method restored stability of the spinopelvic junction and allowed for early mobilization. At her 18-month follow-up visit, she showed minimal disability score (10%) on the Oswestry Disability Index. In conclusion, sacral fractures are considered exceedingly rare to occur in isolation and in young healthy patients.

Correlation between plain X-ray measurements and DXA scans, and its possible use as a screening tool for performing DXA scans.

PURPOSE: The purpose of this study is to determine if there is a relationship between radiological parameters measured using a plain X-ray and DXA scan score, and whether a plain X-ray can be used as surrogate imaging modality when DXA scan is not readily available. METHODS: We included all patients who had both a DXA scan and a pelvis X-ray done from 1 January 2013 to 31 December 2017. Bone mineral density had been measured by DXA scanning of the femoral neck and the spine. Osteoporosis was defined by T-score of any site less than -2.5. Cortical thickness indices on the AP radiograph were calculated. RESULTS: Sixty patients were involved in the study and were divided into two groups. Group A had 22 patients who had a T-Score on their DXA Scans ≤-2.5 SD at the femur neck or the spine with median ± SD (-2.5 ± 0.8, -2.8 ± 1.0), respectively. Group B had 38 patients who had a T-score on their DXA Scans of >-2.5 at the femur neck and the spine with median ± SD (-1.2 ± 0.9, -1.3 ± 1.0), respectively, which was significantly higher than the T-score of osteoporotic (group A) patients (P = .000) at both sites of measurement. The cortical thickness index (CTI) was significantly higher (P = .027) in group B mean ± SD (0.56 ± 0.07), compared with (0.51 ± 0.08) that in group A. CONCLUSION: DXA imaging remains the gold standard for diagnosing osteoporosis and we advocate the use of CTI to detect the patients who need DXA screening in places where this modality is not readily available.

Validation of the cultural adaptation of the Kujala score in Arabic.

BACKGROUND: Patellofemoral pain is a common condition. The Kujala score is a well-established scoring system to assess anterior knee pain and has been translated into many languages including Arabic. The purpose of this cross-sectional study is to culturally adapt the Arabic version of the Kujala score and determine its validity. METHODS: The Kujala score is composed of 13 multiple-choice questions. We modified two questions in the score; running and squatting, and were replaced with questions related to walking on different terrain and prostration, each with the same number of answer choices as the original questions so as not to affect the final score. These modifications were written in Arabic by the same group who translated and validated the original score into Arabic. The original and modified Kujala scores was printed and given to patients complaining of patellofemoral pain to be filled during their visit to the orthopedic outpatient clinics. Final scores for the original and modified questionnaires were calculated. Data was analyzed using SPSS statistics version 21.0 measuring Cronbach's alpha, intraclass correlation coefficient, and Pearson correlation. RESULTS: Ninety-four patients were included in the study, 28 (29.8%) men and 66 (70.2%) women. The mean age for the included patients was 43.67 (± 14.46) years. The mean score for the modified initial questionnaire was 63.91 (± 16.32), and the mean score for the modified re-test questionnaire was 66.52 (± 17.50). There was a statistically significant difference between the mean scores (p = 0.041), with a mean difference of 1.97 (95% CI 0.08 to 3.856). We found a significant strong correlation between the score before and after changing the questions with a p value of < 0.001. CONCLUSIONS: The culturally modified Arabic Kujala questionnaire is shown to be a valid, well-designed tool and an appropriate method of measuring patellofemoral pain.

Knowledge, Practice, and Attitude Toward COVID-19 Among Physicians in Jordan and Palestine: Cross-Sectional Study.

BACKGROUND AND OBJECTIVES: Coronavirus disease-2019 (COVID-19) is an emerging disease threatening the world with a rapid increase in cases and deaths since it was first identified in December 2019. Adequate knowledge, practice, and attitudes (KPA) toward COVID-19 among physicians at the frontline defense against the COVID-19 pandemic may enhance their ability to avoid the risk of self-infection, decrease mortality, and provide adequate medical care service in this pandemic. This study aimed to assess KPA toward COVID-19 among physicians in Jordan and Palestine. METHODS: This is a cross-sectional study using an online survey conducted from 10 April to 26 April 2020 among Jordan and Palestine physicians. Invitations were sent to physician groups on Facebook and WhatsApp. This survey contains 36-items, divided into four main sections to assess the participants' socio-demographic characteristics, knowledge, practice, and attitude about COVID-19. RESULTS: A total of 454 physicians participated in this study. The mean score of basic knowledge was 4.4 ± 0.8 (range 2-4). There were significant differences between basic knowledge mean scores among physicians in different professional degrees and physicians in various health sectors (P=0.0315, P=0.0137, respectively). The mean scores of self-protection measures, were 6.1 ± 1.1 (range 3-7) and measures if physician self-suspected of COVID-19 were 9.9± 1.1 (range 5-11). The mean score of attitudes toward COVID-19 was 41.5 ± 3.3 (range 21-45) and significantly related to the age and different experience years (P=0.0022, P=0.0077, respectively). CONCLUSION: As the global threat of COVID-19 continues to emerge, physicians from Jordan and Palestine showed adequate KPA toward COVID-19. There was a significant difference in knowledge level and attitude between physicians. Policymakers and physicians should keep continuous educational activities, training, and follow-up updates during this pandemic.

The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery.

BACKGROUND: Selective nerve root block (SNRB) is a procedure that can be used as a diagnostic or a therapeutic method. SNRB can be used in multiple sites, including cervical and lumbar . Our study aims to investigate the clinical effectiveness of the use of fluoroscopically guided therapeutic selective nerve root block as a non-surgical symptom management of lumbar radiculopathy. PATIENTS AND METHODS: This is a prospective study of therapeutic nerve root block in 76 patients with low back pain and/or sciatica at Jordan University Hospital. Data was collected by independent clinical interviewers, and visual analogue score (VAS) was used to measure pain severity. RESULTS: A total of 76 patients, 25 (32.8%) males and 51 (67.2%) females, underwent SNRB. 69 (90.7%) patients improved immediately after the procedure. Out of the total, 22 (28.9%) patients showed a long-term relief of symptoms and did not experience any recurrence during the three months of follow-up, while 47 (61.8%) experienced a recurrence of pain. In patients experiencing recurrence of symptoms, 35 needed surgery. CONCLUSION: Therapeutic SNRB is an important procedure in the pain management of patients with lumbar radiculopathy caused by lumbar disc prolapse and foraminal stenosis. Our study showed that avoidance of surgery was achieved in up to 54% of patients; pain relief for at least 6 months was achieved in up to 29% of patients after a single SNRB. This makes it a very good second line of management after conservative treatment and a possible method to delay, and sometimes cease, the need for surgery.

The Yield of Lumbosacral Spine MRI in Patients with Isolated Chronic Low Back Pain: A Cross-Sectional Study.

BACKGROUND: The role of routine lumbosacral MRI in patients presented with isolated chronic low back pain (CLBP) is still unclear. Most patients with CLBP will show diverting degenerative changes on MRI. As it is uncertain whether surgical treatment of degenerative MRI changes results in alleviation of back pain or not, the necessity of doing a diagnostic lumbosacral MRI remains questionable. This study aimed to evaluate the yield of lumbosacral MRI among Jordanian patients presented with isolated CLBP. METHODS: We reviewed medical records of all patients who presented to neurosurgery outpatient clinic at Jordan University Hospital from December 2016 to December 2019. Only patients with a chief complaint of isolated CLBP were included. We obtained the relevant data from the computerized medical files and detailed radiological findings from their MRI reports. RESULTS: One hundred and sixty-seven patients (167) matched the inclusion criteria. We reported positive findings in MRI in 112 patients (67%), but 55 patients (32.93%) had normal MRI findings. Dehydration of intervertebral disc was the most common finding. Positive MRI findings were most evident in the middle-age group (41-60 years old). Disc protrusion finding in middle-aged females was significantly less prevalent than males (P = 0.012). CONCLUSION: Jordanian patients presented with CLBP have similar worldwide patterns of lumbar degenerative changes. Providing that near one-third of patients with CLBP have normal MRI findings, we suggest following a streamlined protocol for imaging of patients presented with CLBP to reduce healthcare costs.

Cervical Myelopathy Due to Ochronosis: An Intraoperative Suspicion.

BACKGROUND Alkaptonuria (AKU) is a rare metabolic disease caused by a deficiency in homogentisic acid oxidase, which leads to the accumulation of homogentisic acid dark pigments in tissues such as bones, ligaments, and tendons. Long-term duration of this condition, termed ochronosis, can result in degenerative arthropathy involving the spine and large joints. CASE REPORT This report describes a 55-year-old Jordanian woman presenting with chronic neck and lower back pain. History, physical examination, and radiological imaging indicated cervical myelopathy and lumbar spine degeneration. Two-level anterior cervical discectomy and fusion was performed successfully. Intra-operatively, the cervical discs were observed to be black, suggesting a diagnosis of alkaptonuria, which was later confirmed by genetic testing. A detailed history and physical examination revealed the absence of classical features of AKU. CONCLUSIONS Intraoperative detection of black disc material suggests the need for further tests to diagnose AKU, especially in indolent patients who did not have classical clinical features. Surgical management may improve outcomes in patients with cervical myelopathy due to ochronosis.

Safety of the LCP Pediatric Hip Plate in Proximal Femoral Osteotomy in Children with Cerebral Palsy.

PURPOSE: Proximal femoral osteotomy in cerebral palsy patients is a demanding procedure. The fixation of the osteotomy can fail due to the weak osteoporotic bone. The LCP pediatric hip plate with its good grip makes these procedures safe. The aims of the present study are to evaluate the radiological outcome of proximal femoral osteotomy that was fixed with the pediatric LCP in cerebral palsy patients and to raise safety issues regarding its low rate of complications. PATIENTS AND METHODS: Sixteen patients with cerebral palsy who were operated in our department were included in this retrospective study. Data collected from medical charts and X-ray measurements retrospectively reviewed. RESULTS: In total, 16 patients (21 hips), ie, 9 males and 7 females, were included in this analysis. The mean age at the time of the index surgery was 11.9 years (5.9-18.0). The mean follow-up period was 4.78 years (1.5-8.0). Five patients had bilateral hip involvement and 11 had unilateral involvement. All patients had spastic cerebral palsy. The mean values of varus correction and de-rotation were 25° (0°-45°) and 35° (20°-50°), respectively. Neck shaft angle and the Reimer's migration index were significantly improved postoperatively (p<0.01 for both). Seventeen hips showed complete consolidation within 14 weeks of fixation and four hips needed 16 weeks. These four hips were in three patients who were 16 years of age or older. The correlation between age at surgery and the time needed for consolidation was statistically significant (p=0.005). Avascular necrosis, revision surgeries, failure of fixation, acetabular penetration, screw loosening or fracture of the femur were not seen in this study. CONCLUSION: The LCP pediatric hip plate can be used safely in CP patients. The plate provides a strong stable fixation on osteoporotic bone with a low rate of complications.

The prevalence of low back pain among female hospital staff at childbearing age.

BACKGROUND: Low back pain (LBP) is considered the most common work-related musculoskeletal disorder among female healthcare workers. The aim of this study is to compare the prevalence of LBP and non-ergonomic risk factors between female nurses, office workers, and patient transporters, and the effect of pain on job performance. METHODS: Based on semi-structured interviews, we conducted a cross-sectional study on Jordanian female hospital workers between January and July, 2017. RESULTS: We included 209 participants with a mean age of 35.57 ± 8 years from four Jordanian medical centers. Nurses have significantly higher frequency of LBP (82.5%; p = 0.05) compared to both office workers (67.5%) and patient transporters (68.6%). The mean difference in pain score using Visual Analogue Scale (VAS) after treatment varied significantly (p = 0.003), since it was 28.2 (±35.4) for office workers, compared to 22.8 (±26.5) for nurses and 6.5 (±33.7) for patient transporters. A higher frequency of nurses reported that LBP affected their job performance (64.9%; p = 0.013), and 43.3% of them reported having previous sick leaves due to LBP (p = 0.008). CONCLUSIONS: LBP is common among female hospital workers, with significantly higher prevalence among female nurses when compared to other female hospital staff.

The short-term impact of COVID-19 pandemic on spine surgeons: a cross-sectional global study.

PURPOSE: The outbreak of COVID-19 erupted in December 2019 in Wuhan, China. In a few weeks, it progressed rapidly into a global pandemic which resulted in an overwhelming burden on health care systems, medical resources and staff. Spine surgeons as health care providers are no exception. In this study, we try to highlight the impact of the crisis on spine surgeons in terms of knowledge, attitude, practice and socioeconomic burden. METHODS: This was global, multicentric cross-sectional study on 781 spine surgeons that utilized an Internet-based validated questionnaire to evaluate knowledge about COVID-19, availability of personal protective equipment, future perceptions, effect of this crisis on practice and psychological distress. Univariate and multivariate ordinal logistic regression analyses were used to evaluate the predictors for the degree of COVID-19 effect on practice. RESULTS: Overall, 20.2%, 52% and 27.8% of the participants were affected minimally, intermediately and hugely by COVID-19, respectively. Older ages (ß = 0.33, 95% CI 0.11-0.56), orthopedic spine surgeons (ß = 0.30, 95% CI 0.01-0.61) and those who work in the private sector (ß = 0.05, 95% CI 0.19-0.61) were the most affected by COVID-19. Those who work in university hospitals (ß = - 0.36, 95% CI 0.00 to - 0.71) were affected the least. The availability of N95 masks (47%) and disposable eye protectors or face shields (39.4%) was significantly associated with lower psychological stress (p = 0.01). Only 6.9%, 3.7% and 5% had mild, moderate and severe mental distress, respectively. CONCLUSION: While it is important to recognize the short-term impact of COVID-19 pandemic on the practice of spine surgery, predicting where we will be standing in 6-12 months remains difficult and unknown. The COVID-19 crisis will probably have an unexpected long-term impact on lives and economies.

Use of magnetic resonance imaging to determine laterality of meniscal size in healthy volunteers.

INTRODUCTION: The menisci are responsible for several functions. They are shock absorbers during dynamic loading on the knee and provide a broader surface area on which to distribute stress evenly to the tibia and femur. These functions allow for smoother movement and greater stability of the knee joint. Meniscal injury can be a great impediment to the function of the knee. Therefore, in the case of meniscal injury, our main concern is the relief of patient symptoms, followed by consequent restoration of meniscal function to the greatest of our ability. To prevent the long terms effects of a meniscectomy, meniscal allograft transplantation (MAT) was developed. The potential of using the size of the contralateral healthy menisci, to determine the size of the menisci to be replaced, will be discussed. METHODS: Knee MRIs done on healthy patients in the past 5 years were reviewed. Magnetic Resonance Imaging was performed using a 3-T scanner. Each individual was examined with knee joints in full extension. Measurements were performed two separate times, two weeks apart. A mean of three measurements was made during each session to reduce error. Thirty-eight normal bilateral knee joints MRIs remained (16 males, 22 females). Participants were sampled from the institutional Picture Archiving and Communication System (PACS). Age, gender, and the medial meniscal and lateral meniscal size of both knees were recorded. The laterality of the menisci was compared between both knees in each patient. RESULTS: A total of 38 patients were included in this study, with a mean age of 37.39 (±9.50) years. They were 16 (42.1%) men and 22 (57.9%) women. We didn't find any significant difference in the mid-coronal section between left and right knees meniscal measurements. None of the measurements were significantly different between men and women. There was no significant difference in the medial mid-sagittal section or lateral mid-sagittal section between left and right knee meniscal measurements. CONCLUSION: The results obtained in this study may support the use of MRI of the bilateral knee to obtain an appropriately sized allograft.

Association between mobile phone use and neck pain in university students: A cross-sectional study using numeric rating scale for evaluation of neck pain.

OBJECTIVE: Mobile phones are reliable devices for communication and entertainment. However, their utilization for prolonged periods in flexed neck position is linked to neck and shoulders pain. The main purpose of this study is to investigate the association between neck pain and the duration of device use, taking into consideration gender, age, and the most frequent position in which students use their devices. SUBJECTS AND METHODS: Based on a self-administered online questionnaire, we filled 500 questionnaires between February 15th, 2017 and March 18th, 2017. The study sample included healthy students from health care faculties regardless of their age, gender, or handedness. RESULTS: Analysis of the predictors for pain severity showed that age (p = 0.04) and duration of use (p = 0.001) were significantly associated with the severity of neck pain, while only the duration of use was significantly associated with pain duration (p = 0.036). Subjects were divided into two groups according to the pain score, 75.8% had pain severity equal or less than 4/10 and 24.2% had pain severity more than 4/10. Of those with pain severity >4, 5.8% of students sought medical help at the emergency department and 12.4% visited clinics, compared to only 0.3% seeking medical advice at an emergency department and 4.2% visiting clinics in the group with pain severity of ≤4 (p<0.001). Regarding the use of analgesia in the two groups, 44.6% of subjects with pain severity of >4 used analgesia, compared to only 12.1% in subjects with pain severity of ≤4 (p< 0.001). CONCLUSION: This study demonstrates a significant positive correlation between the duration of mobile phone use and the duration and severity of neck pain. Furthermore, the increased severity of neck pain places a huge burden on the healthcare system.

Validation of the Arabic version of the Kujala patellofemoral pain scoring system.

BACKGROUND: Patellofemoral knee pain is a common cause of anterior knee pain. The Kujala anterior knee pain score is a scoring system for the clinical assessment of disease severity. The purpose of this cross-sectional study was to validate an Arabic translation of the original Kujala anterior knee pain score to assess Arabic-speaking patients with patellofemoral pain syndrome. METHODS: The Kujala anterior knee pain score was translated into Arabic by a group of native Arabic and native English speakers including orthopedic surgeons, residents, and a medical student. Questionnaires were filled by 127 patients visiting our outpatient department complaining of anterior knee pain diagnosed clinically and after exclusion of other pathologies. Questionnaires were re-filled at least 2 weeks later via phone contact from a member of our team. After exclusions, 97 questionnaires were analyzed for reliability using Cronbach's alpha for the scoring system's internal consistency and intraclass correlation coefficient for test-retest analysis. RESULTS: The mean score of the questionnaire before the follow-up was 62.38 (±17.78) and 64.02 (±18.47) after the follow-up. The scoring system's internal consistency measured via Cronbach's alpha was 0.824. Average ICC for the scoring system was 0.948 (CI: 0.923-0.965) and for single measures, 0.902 (CI: 0.856-0.933). Further, 94.8% of patients were contacted before initiating physiotherapy. Forty-six of the patients (47.4%) showed improvement in their scores when contacted, 44 patients (45.4%) showed a slight worsening of their scores and seven patients' (7.2%) scores were unchanged. CONCLUSIONS: The Arabic translation of the Kujala anterior knee pain score is a valid, reliable, useful, and easy-to-interpret scoring system to assess Arabic-speaking patients with patellofemoral pain syndrome.

Late-presenting developmental dysplasia of the hip in Jordanian males. A retrospective hospital based study.

OBJECTIVES: To describe the pattern of developmental dysplasia of the hip (DDH) in late presenting Jordanian male patients and identify the risk factors and associated findings. METHODS: This is a retrospective study of 1145 male patients who attended the Pediatric Orthopedic Clinic for a DDH check up. This study was carried out in the Orthopedic Section, Special Surgery Department, Faculty of Medicine, The University of Jordan, Amman, Jordan between March 2011 and October 2014. Data was collected from medical records, and x-ray measurements were evaluated.  RESULTS: Of the 1145 male patients, 43 (3.75%) with 70 involved hips were diagnosed with late- presenting DDH. Being a first-born baby resulted in 41.9% increased risk for DDH. Cesarian delivery was significantly associated with an increased risk of hip dislocation (p=0.004) while normal delivery was significantly associated with acetabular dysplasia (p=0.004). No predictable risk factors were found in 44.2% patients with DDH. Bilateral cases were more common than unilateral cases: (26 [60.5%] versus 17 [39.5%]). Limited abduction was a constant finding in all dislocated hips (p less than 0.001). Associated conditions, such as club foot and congenital muscular torticollis were not observed.   CONCLUSION: Cesarian section is a significant risk for dislocated hips while normal delivery is significantly associated with acetabular dysplasia. Bilateral DDH is more common than the unilateral. Club foot and torticollis were not observed in this series.

Bilateral primary psoas abscesses due to methicillin-resistant Staphylococcus aureus in a neutropenic patient: a case report.

BACKGROUND: Pyogenic abscess of psoas muscles is a rare condition. Psoas abscess due to methicillin-resistant Staphylococcus aureus is an emerging and rare infection and so far the related data are scarce. CASE PRESENTATION: We report the rare case of primary and bilateral large psoas abscesses due to methicillin-resistant Staphylococcus aureus in a 54-year-old Arab Jordanian woman with breast cancer who had neutropenia after starting chemotherapy. She was diagnosed 50 days after onset of symptoms. However, despite this delay in diagnosis and the large size of the abscesses, she had a full recovery. She was treated with antibiotics and percutaneous drainage and was doing very well at a follow up of 18 months. CONCLUSIONS: Psoas abscess due to methicillin-resistant Staphylococcus aureus might have insidious presentation with extensive disease especially in immunocompromised patients. However, it can be managed effectively with percutaneous catheter drainage and appropriate antibiotic therapy.

Incidental intraosseous pneumatocyst with gas-density-fluid level in an adolescent: a case report and review of the literature.

Intraosseous pneumatocyst is a gas containing lesion located within a bone. It is a relatively rare condition of unclear etiology and with an undetermined natural course. Gas-density-fluid level pneumatocyst is even rarer. Pneumatocyst is frequently seen in adults but rarely reported in pediatrics. The lesion is usually small and is seen in the vertebral bodies as well as around the sacroiliac joints. Rarely does it occur in other parts of the skeleton. We are reporting a case of large blood signal intensity containing intraosseous pneumatocyst in a 14 year old boy and reviewing other pediatric cases of pneumatocysts as well as those with gas-density-fluid level. The recognition of this incidental rare benign lesion is essential to avoid over investigation and an inappropriate aggressive intervention.