Conjoined lumbosacral nerve root: a case report.

BACKGROUND: In patients with conjoined nerve roots, hemilaminectomy with sufficient exposure of the intervertebral foramen or lateral recess is required to prevent destabilization and ensure correct mobility of the lumbosacral spine. To the best of our knowledge, no case reports have detailed the long-term course of conjoined nerve roots after surgery. CASE PRESENTATION: We report the case of a 51-year-old Japanese man with a conjoined nerve root. The main symptoms were acute low back pain, radiating pain, and right leg muscle weakness. Partial laminectomy was performed with adequate exposure to the conjoined nerve root. The symptoms completely resolved immediately after surgery. However, the same symptoms recurred 7 years postoperatively. The nerve root was compressed because of foraminal stenosis resulting from L5-S disc degeneration. L5-S transforaminal lumbar interbody fusion was performed on the contralateral side because of an immobile conjoined nerve root. At 44 months after the second surgery, the patient had no low back pain or radiating pain, and the muscle weakness in the right leg had improved. CONCLUSIONS: This is the first report of the long-term course of conjoined nerve root after partial laminectomy. When foraminal stenosis occurs after partial laminectomy, transforaminal lumbar interbody fusion from the contralateral side may be required because of an immobile conjoined nerve root.

Decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy: a case report.

BACKGROUND: Intrathecal baclofen therapy can substantially improve symptoms in most patients with severe spasticity due to traumatic spinal cord injury, multiple sclerosis, or cerebral paresis. To the best of our knowledge, decompression surgeries at the intrathecal catheter insertion site in patients with a preexisting intrathecal pump for drug delivery have not been reported. CASE PRESENTATION: We report the case of a 61-year-old Japanese man with lumbar spinal stenosis who underwent intrathecal baclofen therapy. We performed decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy. The yellow ligament was removed by partial resection of the lamina under a microscope to avoid damage to the intrathecal catheter. The dura mater was distended. No obvious cerebrospinal fluid leakage was observed. Postoperatively, lumbar spinal stenosis symptoms improved, and spasticity remained well controlled with intrathecal baclofen therapy. CONCLUSIONS: This is the first reported case of lumbar spinal stenosis decompression at an intrathecal catheter insertion site during intrathecal baclofen therapy. Preoperative preparation is necessary, as the intrathecal catheter may be replaced during surgery. We performed surgery without removing or replacing the intrathecal catheter, taking care not to damage the spinal cord by migrating the intrathecal catheter.

Bilateral simultaneous asymmetric hip fracture without major trauma in an elderly patient: a case report.

BACKGROUND: Simultaneous bilateral hip fractures without major trauma in the elderly are rare and usually symmetrical. To the best of our knowledge, only two cases of bilateral simultaneous asymmetric hip fracture in the elderly without major trauma have been reported. CASE PRESENTATION: We present the case of a 90-year-old Japanese man with simultaneous bilateral asymmetric hip fractures with trochanteric fracture on the right side and greater trochanteric fracture on the left side. He complained of dyspnea at midnight and was referred to our emergency department. He was admitted to the internal medicine department for bacterial pneumonia treatment. On the 8th day of hospitalization, he was referred to our orthopedic surgery department for hip pain and was found to have fractures of both hips. Computed tomography findings showed that the left femoral neck fracture was an old fracture, while the left greater trochanteric fracture and the right trochanteric fracture were fresh fractures. He was surgically treated through open reduction and internal fixation with an intramedullary nail on the right and hemiarthroplasty on the left in supine position, performed during the same surgical sessions on the 12th day of hospitalization. CONCLUSIONS: We report a new form of simultaneous bilateral asymmetric hip fracture in the elderly. The fracture types of the case were femoral trochanteric fracture and greater trochanteric fracture of the femur, which were different from the fracture types in the previously reported two cases. Clinicians should be aware of the possibility of simultaneous bilateral hip fractures, especially in the elderly.

Quantitative differentiation of tendon and ligament using magnetic resonance imaging ultrashort echo time T2* mapping of normal knee joint.

BACKGROUND: Ligaments and tendons are difficult to differentiate on conventional magnetic resonance imaging (MRI). Ligaments and tendons are different histologically, and tendon graft ligamentization is known to occur after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To quantify and differentiate the ultrashort echo time T2* (UTE-T2*) values of normal knee ligaments and tendons using a 1.5-T MRI scanner. MATERIAL AND METHODS: The right knees of 12 healthy volunteers (6 men, 6 women; mean age = 30.8 ± 9.6 years) were scanned using a UTE-T2* sequence and the UTE-T2* values of the proximal, middle, and distal portions of the ACL, posterior cruciate ligament (PCL), and patellar tendon (PT) were evaluated. Two doctors manually drew the regions of interest four times and intra- and inter-observer reliability were evaluated by intraclass correlation coefficients. RESULTS: The UTE-T2* values of ACL at the proximal, middle, distal, and mean were 12.0 ± 2.3, 11.3 ± 2.3, 12.3 ± 2.6, and 11.9 ± 2.4 ms, respectively. The UTE-T2* values of the PCL at each site were 6.9 ± 1.5, 9.0 ± 1.8, 8.8 ± 2.4, and 8.3 ± 2.1 ms, respectively. The UTE-T2* values of the PT at each site were 7.1 ± 1.7, 4.3 ± 1.7, 4.3 ± 1.8, and 5.2 ± 2.1 ms, respectively. Both intra- and inter-observer reliability showed high agreement rates. There were significant differences among the ACL mean, PCL mean, and PT mean, with a P value <0.01 in all cases. CONCLUSION: This study confirms that UTE-T2* mapping can quantify the ACL, PCL, and PT, and tendons and ligaments can be differentiated using the UTE-T2* values in normal volunteer knee joints.

Intrathecal baclofen therapy for severe spasticity in an adult with tethered cord syndrome: a case report.

BACKGROUND: Patients with tethered cord syndrome often suffer severe spasticity. To the best of our knowledge, intrathecal baclofen (ITB) therapy in a patient with tethered cord syndrome has not been reported previously. We describe a case in which ITB therapy was useful for treating severe spasticity in an adult with tethered cord syndrome. CASE PRESENTATION: We present the case of a 50-year-old Japanese woman with tethered cord syndrome and related conditions suffering from severe spasticity and pain in the lower limbs. She was born with a lumbosacral myelomeningocele, which was closed in the neonatal period. For 4-5 years before this presentation, spasticity in the lower limbs had been exacerbated without any obvious cause. She received rehabilitation and pharmacotherapy from a local doctor, but symptoms were unimproved, and her previous doctor referred her to this department. A test with 50 µg of intrathecally delivered baclofen showed total relief of spasticity and pain, so a pump was implanted for continuous baclofen delivery. During 24 months of follow-up, spasticity has remained under excellent control with baclofen at 38.5-41.0 µg/day. CONCLUSIONS: ITB therapy proved extremely effective in this adult with severe spasticity from tethered code syndrome.

Thoracic extradural malignant melanoma with unknown primary.

Primary extradural spinal melanoma is a very rare lesion. Here, we report a thoracic extradural malignant melanoma in a 77-year-old male. MRI showed a dorsal spinal extradural tumour at the T6-T8 level. The tumour showed hyperintensity on T1W imaging and mixed hypointensity and hyperintensity on T2W imaging. Gadolinium-enhanced MRI showed high enhancement on the lesion. Information on imaging findings for extradural spinal melanoma appears very limited. We discuss the MRI findings from this case, which can be considered typical of extradural spinal melanoma and review the literature.

Partial lateral meniscus anterior root injuries during anatomical single-bundle anterior cruciate ligament reconstruction are likely to occur in women with small skeletons.

PURPOSE: This study aimed to investigate the occurrence and characteristics of lateral meniscus anterior root injuries during anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Between 2011 and 2018, 70 women who had ACL injuries without lateral meniscal tears underwent anatomical single-bundle ACL reconstruction. Using computed tomography, the anatomical relationship between the predicted lateral meniscus anterior root insertion and the tibial tunnel was retrospectively assessed, and the patients were divided into partial lateral meniscus anterior root injury and intact groups. The demographic characteristics, the distances between bony landmarks, the tibial tunnel sizes, and lateral meniscal extrusion assessed by magnetic resonance imaging were compared between the two groups. RESULTS: Thirteen of the 70 patients had suspected partial lateral meniscus anterior root injuries. Patient height was significantly shorter in the injury group than in the intact group (157.7 ± 6.4 vs. 161.4 ± 5.4 cm: p = 0.03); the distance from the apex to the bottom of the slope of the medial intercondylar ridge was significantly shorter in the injury group than in the intact group (15.1 ± 1.9 vs. 16.7 ± 1.4 mm: p = 0.001). CONCLUSIONS: Partial lateral meniscus anterior root injury during anatomical single-bundle ACL reconstruction was suspected in 18% of cases. Patient height and the distance between bony landmarks were significantly shorter in the injury group than in the intact group. Surgeons should understand that even a slight deviation of the tibial tunnel position can lead to partial lateral meniscus anterior root injury in patients with small skeletons. LEVEL OF EVIDENCE: IV.

Incidence of injury in young handball players during national competition: A 6-year survey.

BACKGROUND: An updated injury surveillance of young handball players is needed because of the increased risk of injury in recent handball games with increased intensity. This study examined acute injuries in young handball players during games. METHODS: We retrospectively assessed the injuries occurring during 6 national competitions, including 550 games from 2013 to 2018, held in March of each year. All players were 13 or 14 years old. RESULTS: In total, 169 injuries were reported. The number of match injuries per 1000 player hours was 26.5. The injury incidence in boys was higher than that in girls (p = 0.001). No significant differences were found in injury incidence according to the position and date during the tournament (p = 0.108 and 0.483, respectively). Of all injuries, 43.2% were in the lower extremities and 20.7% affected the upper extremities. Most injuries occurred in the head/face (n = 53, 31.4%), followed by the ankle/foot (n = 41, 24.3%), knee (n = 23, 13.6%), and wrist/hand (n = 22, 13%). The most common injury type was sprain (n = 64, 37.9%), followed by contusion (n = 50, 30.0%) and wound (n = 35, 20.7%). In field players, ankle sprain was the most frequent diagnosis, followed by head/face wound and contusion. In contrast, contusion was the main cause of injury in goalkeepers, followed by wound on the head/face. CONCLUSIONS: Preventive measures focussing on sprains in the lower extremity and improved skill in ball-handling technique should be considered to prevent head/face and wrist/hand injuries, especially in boys. STUDY DESIGN: Retrospective cohort study.

Lateral meniscus posterior root tear in anterior cruciate ligament injury can be detected using MRI-specific signs in combination but not individually.

PURPOSE: The purpose of this study was to evaluate (1) the diagnostic value of using single and multiple magnetic resonance imaging (MRI) findings for lateral meniscus posterior root tear (LMPRT) detection in anterior cruciate ligament (ACL) injury and (2) the influence of time from ACL injury to MRI assessment on LMPRT detection. Finally, we investigated the relationship between LMPRT and bone bruising. METHODS: In all, 231 knees with ACL injury, 32 with LMPRT, were retrospectively assessed. Cases were evaluated for LMPRT based on the cleft, ghost, and truncated triangle signs, used individually or in combination. To assess the influence of the timing of the MRI assessment on LMPRT detection, we also evaluated the overall sensitivity, specificity, and accuracy in cases in which MRI was performed within 2 weeks of injury. The number of condyles with bone bruising was assessed and then compared between patients with and without LMPRT. RESULTS: Although the sensitivity and specificity of the three signs individually were 34.4-65.6% and 94.0-97.0%, when at least one of these signs was positive, the sensitivity and specificity were 84.4% and 90.5%, respectively. However, the diagnostic value of each sign when MRI was performed within 2 weeks of injury was lower than the overall value. There was a significant difference in the number of condyles with bone bruising between the LMPRT (3 ± 1) and non-LMPRT (2 ± 2) groups. CONCLUSIONS: Although the sensitivity of each sign for LMPRT was low, LMPRT could be detected adequately if these signs were used in combination. Therefore, surgeons should detect LMPRT using these three signs in combination, not individually. LEVEL OF EVIDENCE: IV.

Investigation of extrusion of the medial meniscus under full weight-loading conditions using upright weight-loading magnetic resonance imaging and ultrasonography.

BACKGROUND: Meniscal morphology under full weight-loading conditions is currently unknown. This study aimed to evaluate extrusion in the medial meniscus between unloaded and upright-loaded conditions in healthy adults using upright magnetic resonance imaging (MRI) and ultrasonography and to investigate the relationship between MRI and ultrasonography in upright-loaded conditions. METHODS: Eighteen healthy adult volunteers (13 men and 5 women) participated in the study. MRI and ultrasonography were performed with patients in the supine, double-leg upright (DLU), and single-leg upright (SLU) positions. Medial, anterior, and posterior extrusions of the medial meniscus against the tibial edge were evaluated and compared across the three positions. Medial extrusion correlations between MRI and ultrasonography were examined. Demographic data and hip-knee-ankle (HKA) angles were measured and correlated with changes in the medial extrusion. The medial meniscal extrusions detected via MRI and ultrasonography were compared across the three positions. Correlations were examined using Pearson's correlation coefficients. RESULTS: Negative correlations were found between the change in medial extrusion of the medial meniscus and HKA angle (MRI: r = -0.52, ultrasonography: r = -0.51). Although no significant differences among the three conditions were observed for the anterior and posterior extrusions of the medial meniscus, the medial extrusion of the medial meniscus was significantly greater in DLU and SLU positions than that in the supine position for MRI and ultrasonography (P < 0.05). Positive correlations for the medial extrusion of the medial meniscus were found between MRI and ultrasonography in all three positions (supine: r = 0.74, DLU; r = 0.71, SLU; r = 0.61). CONCLUSIONS: Although no significant differences in anterior and posterior extrusions of the medial meniscus were seen across the studied positions, the medial meniscus was found to undergo significant medial extrusion during upright weight-loading conditions. The strong correlation between MRI and ultrasonography highlighted the usefulness of ultrasonography. LEVEL OF EVIDENCE: Level IV.

Relationship between the deep flexion of the knee joint and the dynamics of the infrapatellar fat pad after anterior cruciate ligament reconstruction via ultrasonography.

[Purpose] A sufficient flexion angle of the knee joint after knee surgery leads to higher quality of their life; therefore, here we investigated the relationship between the dynamics of the infrapatellar fat pad and seiza-style sitting via ultrasonography. [Participants and Methods] Twenty-eight patients were enrolled 3 months post-operatively after anterior cruciate reconstruction. They were divided into a "possible" group and "impossible" group, according to whether they could sit in the seiza style. The thickness of the superficial part of the infrapatellar fat pad was measured at 10° and 90° knee flexion on reconstructed knees in the sitting position via ultrasound evaluation. Images were taken to capture the patella apex and tibial tuberosity. The thickness of the superficial part of the infrapatellar fat pad was measured, and the thickness change ratio was calculated. The characteristics of each group were compared. [Results] The superficial part of the infrapatellar fat pad was significantly thinner in the possible group at a 10° knee flexion. The thickness change ratio of the infrapatellar fat pad was significantly greater in the possible group. [Conclusion] The thickness of the infrapatellar fat pad at a 10° knee flexion and the thickness change ratio of the infrapatellar fat pad could affect the possibility of sitting in the seiza style.

Ultrasound-guided injection and the pie crust technique for the treatment of symptomatic bipartite patella.

PURPOSE: This study aimed to investigate the results of a new treatment procedure (ultrasound-guided injection and the "pie crust" technique for lengthening of capsular tendon structures) for symptomatic bipartite patella. METHODS: We retrospectively investigated patient outcomes following the treatment of symptomatic type III bipartite patella with our new technique. Fifteen knees in 14 boys (mean age, 13.0 ± 1.7 years) were included. The procedure involved the injection of 1% lidocaine (2 mL) and triamcinolone acetonide (5 mg) between the patella and fragment. We then punctured 10 sites from one skin puncture to extend lateral capsular tendon structures. The patients were clinically assessed using the Victorian Institute of Sports Assessment (VISA) score before and 1 week, 1 month, and 3 months after the procedure. Patients were also evaluated for complications. RESULTS: The average VISA score was 45.7 ± 4.7 before treatment, 70.6 ± 7.3 at 1 week post-treatment, 84.4 ± 16.6 at 1 month post-treatment, and 88.6 ± 18.3 at 3 months post-treatment. The VISA score improvement from before the procedure to 1 week after the procedure was significant (P < 0.01). There were no complications in any of the patients, who returned to sports at a mean of 4.2 ± 2.1 weeks after the procedure. However, two patients (three knees) had poor results and could not return to action; thus, they underwent surgical treatment 4 months after the ultrasonographic procedure. CONCLUSIONS: This novel method is a potential treatment option for the management of symptomatic bipartite patella in outpatient clinics.

The characteristic findings of an inverted-type discoid lateral meniscus tear: a hidden tear pattern.

BACKGROUND: The purpose of this study was to reveal the clinical history and physical and magnetic resonance imaging (MRI) findings of patients with an inverted-type discoid lateral meniscus (DLM) tear compared with those with a symptomatic and torn discoid meniscus without inverted tear patterns. MATERIALS AND METHODS: Between 2014 and 2016, 12 patients underwent arthroscopic partial meniscectomy for an inverted-type DLM tear (inverted group). We age-matched these patients with 12 controls who were extracted from many normal DLM tear cases in the same period (non-inverted group). The assessment items were traumatic history with the onset of pain, the mean duration between the appearance of symptoms and surgery, preoperative knee range of motion (ROM), positive findings on the McMurray test, knee locking or catching, and characteristic MRI findings. These items were compared between the two groups using χ2 and Student's t-tests. RESULT: All patients in the inverted group had clear trauma with the onset of pain during sports or daily life activities, and 7 of the 12 patients with a non-inverted type of DLM tear had clear trauma. There was a significantly higher rate of traumatic history in the inverted group than in the non-inverted group (P = 0.03). The mean duration between the appearance of symptoms and surgery, preoperative knee ROM, positive findings on the McMurray test, and knee locking or catching were not significantly different between the inverted and non-inverted groups. On MRI, the diagnosis ratio of DLM was significantly higher in the non-inverted group (9/12 cases) than in the inverted group (3/12 cases, P = 0.04). Nine of the 12 inverted-type patients had the characteristic findings of an inverted-type DLM tear, including a duplicated or enlarged posterior horn and blunting of the inner rim, on the sagittal plane of an MRI. CONCLUSION: Patients with inverted-type DLM tears had clear trauma and infrequently had the characteristic MRI findings that are observed in patients with normal DLM tears. Physicians should suspect that an inverted-type DLM tear is present during diagnosis and focus on the posterior horn to find the inverted sign on the MRI sagittal plane. LEVEL OF EVIDENCE: Level III.

Recurrent upper lumbar disc herniation treated via the transforaminal approach using microendoscopy-assisted lumbar discectomy: a case report.

BACKGROUND: Although microendoscopy-assisted lumbar discectomy for lateral or extraforaminal lumbar disc herniations via the lateral approach has previously been reported, microendoscopy-assisted lumbar discectomy for central or paramedian disc herniations via the lateral approach has not been reported. We report the first case of recurrent upper lumbar disc herniation (L2-L3) treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. No microendoscopy-assisted lumbar discectomy for recurrent upper lumbar disc herniation via the transforaminal approach has previously been reported. Percutaneous endoscopic lumbar discectomy via the transforaminal approach is very useful as a minimally invasive surgery for disc herniations. We applied percutaneous endoscopic lumbar discectomy via the transforaminal approach, and invented a new microendoscopy-assisted lumbar discectomy via the transforaminal approach. CASE PRESENTATION: A 79-year-old Japanese man was operatively managed for recurrent L2-L3 herniation. An 18 mm skin incision was made approximately 70 mm from the midline to the lateral side to allow a sufficiently angled trajectory to the extraforaminal space. The transforaminal approach was used. The exiting nerve root was identified along its course inferior to the pedicle. The lateral portion of the pars interarticularis and the facet joint was removed using a high-speed drill under the guidance of an endoscope. The tip of the endoscope was set at the lateral side of the dura mater. The dura mater was retracted medially and gently, and the herniated disc fragments were removed safely. All symptoms were relieved postoperatively. Postoperative magnetic resonance imaging demonstrated disappearance of all herniated disc fragments. A postoperative three-dimensional computed tomographic scan demonstrated the complete preservation of the facet joint. CONCLUSIONS: This is the first report of a case of recurrent upper lumbar disc herniation treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. This procedure allows for the use of a nerve retractor and other instruments to detach adhesions from the dura mater. This procedure has the advantages of clear visualization of the dura mater, exiting nerve root, and traversing nerve root, and diminished risk of nerve injury, and complete preservation of the articular surface of the facet joint.