Primary amyloidoma of the thoracic spine presenting with acute paraplegia

BACKGROUND

Primary solitary amyloidoma of the spine is a rare disease characterized by localized deposition of amyloid. To the best of our knowledge, there have been only 14 cases previously reported in the literature. Patients with focal spinal amyloidoma usually have relatively long symptomatic periods preoperatively, ranging from 3 weeks to 6 years (mean: 12 months). Only two reported patients had acute paraplegia. We add a third case of a thoracic spine amyloidoma presenting with acute paraplegia.

CASE DESCRIPTION

A 65-year-old man presented with a three-day history of progressive paraplegia and urinary retention. He was found to have severe cord compression at T2 on magnetic resonance imaging. He underwent emergent decompressive laminectomy with instrumentation for spinal stabilization. Histopathology revealed abundant amyloid deposits. A systemic work-up was negative for amyloidosis. The patient showed marked neurological improvement with residual mild spastic gait after 1 year.

CONCLUSIONS

Primary spinal amyloidoma with acute paraplegia is rare. One-stage surgery combining prompt decompression and stabilization of the spinal column is mandatory in cases of spinal amyloidoma with acute myelopathy, because primary solitary amyloidoma carries a good prognosis.     

Primary cervical amyloidoma: a case report and review of the literature

Background context

Primary solitary amyloidosis or amyloidoma is a disease process characterized by the focal deposition of amyloid in the absence of a plasma cell dyscrasia with normal serum protein measurements. Solitary amyloidomas affecting the vertebrae are very uncommon but typically affect the thoracic spine. Primary cervical amyloidosis is an exceedingly rare entity with exceptionally good prognosis, but requires diligence of the treating physician to establish the diagnosis and implement the appropriate surgical intervention.

Purpose

This study aimed to present a rare case of primary cervical amyloidosis with long-term follow-up and review the clinical presentation, characteristic imaging findings, diagnostic pathology, differential diagnosis, treatment algorithm, and prognosis of the disease entity. This case demonstrates the progressive resorption of the amyloidoma over time after surgical stabilization. Previous reported cases of primary cervical amyloidosis will also be reviewed.

Study design

This study is a report and review of the literature.

Methods

A 77-year-old woman presented with a several-week history of gradual progressive weakness in her upper and lower extremities. Computed tomography and magnetic resonance imaging demonstrated a retro-odontoid nonenhancing soft-tissue mass, with erosive bony changes and severe mass effect on the upper cervical cord. The patient was taken to the operating room for decompression and posterior spinal stabilization.

Results

Intraoperative tissue specimens demonstrated amyloidosis and extensive systemic workup did not reveal any inflammatory processes, systemic amyloidosis, or plasma cell dyscrasia. Postoperatively, the patient regained full strength and ambulatory status. The patient remains asymptomatic at a 2-year follow-up. A postoperative follow-up magnetic resonance imaging demonstrated complete resorption of the residual amyloidoma.

Conclusions

Primary solitary amyloidosis is a rare form of amyloidosis that is important to differentiate given its excellent prognosis with surgical management. Treatment should include surgical decompression and spinal stabilization. This is the first case report to clinically and radiographically demonstrate the progressive resorption of a primary amyloidoma over time after surgical stabilization in the upper cervical spine. It is imperative that surgeons encountering such lesions maintain a high suspicion for this rare disease entity and advise their pathologists accordingly to establish the correct diagnosis.     

Idiopathic symptomatic epidural lipomatosis of the lumbar spine

Summary.  Background: Symptomatic spinal epidural lipomatosis (SEL) of the lumbar spine is a rare disease, often associated with steroid overload. Idiopathic lipomatosis is even much less frequent. Signs and symptoms depend upon the level and degree of nerve root compression. Diagnosis is best based on MRI. Weight reduction can be curative, however after failure of medical treatment or in severe cases surgical decompression should be performed.  Method: Four patients with severe symptoms of lumbar spinal epidural lipomatosis were treated by surgical decompression. Patient history and neurological examination are described, diagnostic imaging is demonstrated, surgical treatment and outcome are documented. Different surgical techniques including laminectomy, interlaminar fenestration and lateral recess decompression were applied and are discussed.  Findings: All four patients improved after surgery. No surgical complications were observed. Even though limited to four cases this is the second largest series of operated idiopathic spinal epidural lipomatosis.  Interpretation: Surgical decompression was effective in improving symptoms in severe lumbar idiopathic spinal epidural lipomatosis. Published online April 28, 2003  Correspondence: M. Payer, M.D., Hiltbrunnerweg 10, 8713 Uerikon, Switzerland.     

腰椎术后硬膜外血肿的危险因素和临床转归

目的 :探讨腰椎手术后硬膜外血肿形成的危险因素,并随访血肿清除术后患者神经功能恢复情况。方法:2009年1月~2014年1月在北京医院骨科因腰椎管狭窄症或腰椎间盘突出症行腰椎后路减压椎弓根螺钉内固定术的患者共1225例,术后发生硬膜外血肿致马尾神经功能受损的患者共8例,收集和整理血肿患者的一般资料,并对其血肿清除手术后神经功能恢复情况进行随访。采取病例对照研究的方法,按照每1例腰椎术后硬膜外血肿患者随机选取3例诊断、手术方式及手术医师均相同的24例患者作为对照。对两组患者的年龄、性别、高血压病史、糖尿病病史、非甾体类镇痛药物应用、抗血小板聚集药物的应用、是否为翻修手术,及手术融合节段数、手术时间、术中失血量、输红细胞悬液量、是否输注了冰冻血浆进行多元回归分析,采用多元Logistic回归模型确定每个因素是否为硬膜外血肿形成可能的危险因素,计算其OR(Odd′s Ratio)值。结果 :多元Logistic回归模型回归分析结果显示,手术前危险因素是年龄65岁和翻修手术,手术中危险因素是手术时间120min、失血量600ml、手术中输注了冰冻血浆。血肿清除术后神经功能完全恢复者2例,部分恢复者4例,无恢复者2例。结论:患者年龄65岁、翻修手术、手术时间120min、术中出血量600ml、术中输注冰冻血浆是腰椎手术后硬膜外血肿形成的危险因素;血肿清除术后大部分患者神经功能得到不同程度恢复。     

Percutaneous discectomy of the lumbar spine

Summary Ten patients with clinical and radiological evidence of herniated discs at lower lumbar levels were treated with partial discectomy by a lateral percutaneous approach. Eight patients had complete relief from radicular pain and were discharged within four days. They returned to normal daily activity within one month.

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Résumé Dix malades présentant des signes cliniques et radiologiques de hernie discale L3–L4 et L4–L5 ont été traités par discectomie partielle, effectuée par voie per-cutanée à l'aide d'un trocart introduit par voie postéro-externe. Huit de ces patients ont été totalement soulagés de leurs douleurs et ont pu quitter l'hôpital au 4e jour. Ils ont repris une activité normale dans un délai d'un mois.

     

Ultrasonography of the lumbar spine: Sonoanatomy and practical applications

Ultrasonography of the bones and joints has gained considerable ground in the field of rheumatology over the past decade and is now used in everyday practice both for diagnostic purposes and to guide local injections. However, the use of ultrasonography is virtually confined to the peripheral joints, whereas spinal diseases make a major contribution to rheumatology practice. Studies have established that ultrasonography of the lumbar spine is feasible. Adequate equipment and familiarity with spinal sonoanatomy are required. In this update, we suggest starting with a systematic examination of the lumbar spine to assess the various anatomic structures, from the thoracolumbar fascia superficially to the posterior part of the vertebras at the deepest level. The ligaments, erector spinae muscles, facet joints, and transverse processes can be visualized. Ultrasonography can serve to guide injections into the facet joints, about the nerve roots, and into the iliolumbar ligaments; as well as to identify relevant landmarks before epidural injection. Although diagnostic applications are more limited at present, systematic studies of abnormal ultrasonography findings will allow evaluations of the potential usefulness of ultrasonography for diagnosing spinal disorders. The depth of the spinal structures limits the ability to obtain high-resolution images. However, future technical improvements in ultrasound transducers and machines, together with the growing number of physicians trained in ultrasonography, can be expected to benefit the development of spinal ultrasonography in the near future.     

Patient-reported outcomes after lumbar epidural steroid injection for degenerative spine disease in depressed versus non-depressed patients

Background Context

Medical interventional modalities such as lumbar epidural steroid injections (LESIs) are often used in the setting of lumbar spine disorders where other conservative measures have failed. Concomitant depression can lead to worse outcomes in lumbar spine pathology. A number of studies have demonstrated an association between preoperative depression and poor outcomes following surgery, but the effect of depression on outcomes following medical interventional modalities is poorly understood.

Effectiveness of a mucolythic agent as a local adjuvant in revision lumbar spine surgery

Aim of this prospective randomized trial was to analyze the effectiveness of MESNA in chemical dissection of peridural fibrosis in patients who underwent revision lumbar spine surgery. Between January 2003 and October 2006, 30 patients who underwent revision lumbar spine surgery were enrolled in the study. Patients were randomly assigned to one of two groups: a study group (A) and a control group (B). Once peridural fibrosis was exposed, MESNA (Uromixetan MESNA, 50 mg/ml) was intraoperatively applied on the fibrous tissue (Group A) to ease tissue dissection and enter the canal. In patients of Group B, saline solution was used. Surgical time, preoperative and 1 week postoperative hemoglobin (Hb), length of hospitalization (days), and incidence of perioperative complications were evaluated. The blinded surgeon assigned the surgeries to one of four categories as none, minimal, moderate, and severe basing on intraoperative difficulty in dissecting the fibrous tissue and intraoperative bleeding. Statistical analysis used chi-square analysis to evaluate the difference in surgery difficulty and the incidence of intraoperative complications between the two groups. The analysis of surgical time and hemoglobin levels was performed using a one-sample Wilcoxon test and Mann–Whitney U test. Patients in whom MESNA was used intraoperatively (Group A) presented better intraoperative and perioperative parameters with respect to the control group. Average surgical time and decrease in Hb postoperatively were more in the saline group (B) respect to MESNA (A) (P = 0.004 and P = 0.001, respectively), while no difference in average hospital stay was reported between the two groups. Surgeon-blinded intraoperative report on surgical difficulty showed a significant difference between the two groups (P < 0.05). Postoperatively, no complications directly attributable to the use of MESNA were experienced. The incidence of dural tears and intraoperative bleeding from epidural veins were significantly less in Group A with respect to the control group. MESNA contributed significantly to reduce the operative complications, with a diminution of the surgical time and the grade of difficult for the surgeon, confirming its ability as chemical dissector also for epidural fibrosis in revision lumbar spine surgery.     

Impalement injury of the lumbar spine

Impalement is an uncommon injury, which combines aspects of both blunt and penetrating trauma. Particularly, reported cases of impalement injury of the lumbar spine are very rare. We present a case of impalement in which a steel rod penetrated the back into the vertebral body of the lumbar spine as the result of a fall. This injury was treated successfully with irrigation, debridement, and removal of the foreign body in the operating room. Thereafter, a secondary posterolateral interbody fusion (PLIF) procedure was performed due to instability of the lumbar spine. After 1 year, the patient had regained good functional results.     

Determination of inter-spinous process distance in the lumbar spine

Fracture of a spinal segment with minimal or no compression of the vertebral body can be highly unstable. Screening for such an injury in the lumbar spine is often obstructed in a multi-injured patient, because of difficulty in obtaining adequate sagittal radiographs. The position of the spinous processes in relation to each other is the key for proper evaluation of the status of the posterior stabilising structures. The amount of separation or axial rotation of the posterior part of the vertebra that can occur before failure of the posterior structures has not been unambiguously defined. Despite this, it can be assumed that severe separation of the spinous processes indicates a more or less pronounced loss of mechanical support. An analysis of how the posterior spinous processes relate to each other on an anteroposterior (AP) radiograph could obviate this problem. A new, simple and reproducible radiographic tool is presented for screening of an eventual rupture of posterior structures of the lumbar spine. This method is based on measurements of the variation in interspinal process distance between adjacent levels in lumbar spine in a normal population. Two hundred normal AP radiographs of non-injured thoracolumbar spine were studied. The interspinal process distance was measured as the distance between the cranial ends of the adjacent projections of spinous processes on AP radiographs. The mean values and 99% confidence limits for changes in the interspinal process distances between adjacent spinal levels were determined and analysed in relation to age, gender and spinal segment level. An upper limit of a normal difference in distance between the spinous processes at two adjacent levels was determined to be 7–10 mm, depending on age and location in the lumbar spine. A difference in interspinal process distance exceeding 7 mm between two adjacent lumbar levels should alert a surgeon to severe and unstable injury. Received: 18 April 1998 Revised: 2 February 1999 Accepted: 17 February 1999     

中国腰椎研究对世界腰椎医学的贡献

【摘要】 目的：探究中国腰椎研究对世界的贡献。方法：在Web of Science（WOS）核心合集数据库中,对腰椎相关研究的主题词进行文献检索,采用文献计量方法对收集到的文献进行统计和分析;利用数据库（https://www.geenmedical.com）对国家自然科学基金资助的腰椎研究项目进行检索,在国家科学技术奖励工作办公室官网（https://www.nosta.gov.cn/web/index.aspx）下载2000~2020年国家科学技术进步奖资助的项目信息,检索与腰椎研究相关的项目;采用CiteSpace软件对近5年腰椎研究的文献进行可视化研究,分析腰椎研究的趋势。结果：在WOS数据库中,共检索到腰椎相关研究的论著44381篇。其中腰椎间盘退变4977篇,腰椎生物力学2977篇,腰椎间盘突出症5568篇,腰椎管狭窄症6509篇,腰椎滑脱症3861篇,退行性脊柱侧凸1155篇。TOP10国家/地区文章数量显示：美国14742篇,位居第一位;中国5432篇,仅次于美国,位居世界第二位,占比12.2%。文章发表数量方面：腰椎间盘突出症领域,中国为发文量最多的国家;其他相关的腰椎研究,中国的发文量均仅次于美国,位于全世界的第二位。2006~2019年中国国家自然科学基金资助的腰椎研究项目共91项,总资助金额4023万元,研究热点主要包括：腰椎退变、基因、生物力学。2000~2020年中国国家科学技术进步奖资助的腰椎研究项目共计9项,研究热点主要包括：脊柱畸形、骨质疏松、腰椎微创。近5年腰椎研究的趋势主要集中在腰椎退变、腰椎融合、腰椎稳定性、手术治疗原则、手术失败的危险因素、机器学习以及微创手术。结论：中国腰椎研究对世界的贡献巨大,主要表现为以下几个方面：中国多层次的基金资助机构大力资助腰椎相关的研究;中国多个高校及研究机构大力支持腰椎相关研究;众多中国腰椎领域专家高度重视腰椎研究,发表了多篇高水平的研究成果;多篇文章为高被引文献。     

脊柱原发血管外皮瘤的诊治特点

目的探讨脊柱原发血管外皮瘤的诊断和治疗特点。方法回顾1例原发腰椎血管外皮瘤的临床表现、诊断及治疗过程,同时复习国内外相关文献以明确原发脊柱血管外皮瘤的诊治方法。结果脊柱原发血管外皮瘤呈脊柱原发性肿瘤的临床表现,术前和术中难以明确诊断,术后免疫组化病理检查才能确诊。采取边缘切除肿瘤组织后可以较好地重建脊柱的稳定性。结论脊柱原发血管外皮瘤的诊断主要靠病理免疫组化检查,首先应考虑外科手术切除并重建脊柱的稳定性,再辅以放疗,如肿瘤病灶不能切除,应首选放疗,化疗的价值还未得到肯定。     

The flow patterns of caudal epidural in upper lumbar spinal pathology

Epidural steroid injections are an important therapeutic modality employed by spinal surgeons in the treatment of patients with chronic low back pain with or without lumbar radiculopathy. The caudal epidural is a commonly used and well-established technique; however, little is known about the segmental level of pathology that may be addressed by this intervention. This prospective study of over 50 patients aimed to examine the spreading pattern of this technique using epidurography. The effect of variation in Trendelenburg tilt and the eradication of lumbar lordosis on the cephalic distribution of the injectate were investigated. 52 patients with low back pain and radiculopathy underwent caudal epidural. All had 20 ml volume injected, comprised of 5 ml contrast (Ultravist™ Schering) 2 ml Triamcinolone (Adcortyl™ Squibb) and 13 ml local anaesthetic (1% lignocaine). Patients were randomised to either 0° or 30° of Trendelenburg tilt, as referenced from the lumbar spine. Patients were further randomised to presence or absence of lumbar lordosis, which was eradicated using a flexion device placed beneath the prone patient. A lateral image of each sacrum was obtained, to identify variations in sacral geometry particularly resistant to cephalic spread of injectate. The highest segment reached on fluoroscopy was recorded post injection. Fifty-two patients with a mean age of 50 years underwent caudal epidural. Thirty-one were in 0° head tilt, with 21 in 30° of head tilt. In each of these groups, 50% had their lumbar lordosis flattened prior to caudal injection. The median segmental level reached was L3, with a range from T9 to L5. Eradication of lumbar lordosis did not significantly alter cephalic spread of injectate. There was a trend for 30° tilt to extend the upper level reached by caudal injection (p = 0.08). There were no adverse events in this series. Caudal epidural is a reliable and relatively safe procedure for the treatment of low back pain. Pathology at L3/4 and L4/5 and L5/S1 can be approached by this technique. Although in selected cases thoracic and high lumbar levels can be reached, this is variable. If pathology at levels above L3 needs to be addressed, we propose a 30° head tilt may improve cephalic drug delivery. The caudal route is best reserved for pathology below L3.     

Effect of lumbar flexion on the extent of epidural blockade

BACKGROUND AND OBJECTIVES: This study examined the effect of lumbar flexion on the extent of the epidural block during lumbar epidural anesthesia. METHODS: The epidural catheter was introduced at the L3-4 interspace with the patient in the lateral decubitus position with the surgical side down. After administering a test drug (3 mL of 2% lidocaine and 15 mug of epinephrine), the patients were randomly allocated to 1 of 2 groups: Group F (n = 16, lumbar spine flexed) and Group N (n = 17, lumbar spine in the neutral position). In both groups, 2% lidocaine (16 mL) mixed with sodium bicarbonate (2 mL) was administered through the epidural catheter while the patient maintained the lateral decubitus position with the lumbar spine either flexed or in the neutral position. All the patients maintained their respective positions for 5 minutes and were subsequently turned to the supine position. The pinprick block level and the degree of motor blockade were assessed every 10 minutes for 60 minutes after administering the local anesthetics. A 2-dermatomal difference in uppermost block between groups was determined to be clinically significant. RESULTS: The median difference between groups in the uppermost pinprick block level was only 1.5 dermatomes and it did not satisfy our criteria for clinical significance. There were no significant differences between the 2 groups in the lowermost pinprick block level and the degree of motor block. CONCLUSIONS: Lumbar flexion has no clinically relevant effect on sensory spread during epidural anesthesia.     

Functional MRI of the spine: different patterns of positions of the forward flexed lumbar spine in healthy subjects

Since the introduction of the technique of vertical open-configuration systems, efforts have been made to obtain functional lumbar spinal magnetic resonance (MR) images. The purpose of this study was to determine the relation between facet joint orientation and flexion patterns in the lower lumbar spine. Thirty-four normal subjects (18 women, 16 men) were examined in a vertical open 0.5-T MR scanner with T1-weighted gradient echo (GE) sequences. Flexion angles were digitally measured in the sagittal plane and facet joint orientation in the axial plane. The population showed three different functional flexion patterns: 17.6% (n=6) had kyphotic angles in all three lower lumbar levels during forward flexion (type 1), 50% (n= 17) had a lordotic angle at L5/S1 but kyphotic angles at L4/L5 and L3/L4 (type 2), and 32.4% (n=11) showed lordotic angles at L5/S1 and L4/L5 but a kyphotic angle at L3/L4 (type 3). There were statistically significant differences between flexion patterns and mean facet joint orientation: at 4/15 33.3 degrees for type 1, 33.5 degrees for type 2 and 46.2 degrees for type 3; at L5/S1 27.2 degrees for type 1, 46.4 degrees for type 2 and 48.1 degrees for type 3. There were no significant differences between the three groups at L3/L4. The three different flexion patterns in normal subjects and their relation to facet joint orientation have not been described previously. Knowledge of these patterns may lead to a better understanding of physiological spinal movement as a base for future investigations in low back pain patients.     

How to interpret computed tomography of the lumbar spine

Computed tomography (CT) of the spine has remained an important tool in the investigation of spinal pathology. This article helps to explain the basics of CT of the lumbar spine to allow the clinician better use of this diagnostic tool.     

The prevalence of transitional vertebrae in the lumbar spine

Background context

Lumbosacral transitional vertebrae (LSTVs) are a congenital vertebral anomaly of the L5–S1 junction in the spine. This alteration may contribute to incorrect identification of a vertebral segment, leading to wrong-level spine surgery and poor correlation with clinical symptoms. Although several studies describe the occurrence of this anomaly in back pain populations, investigation of the prevalence in the American general population is lacking.

Purpose

To establish the prevalence rates for LSTVs in the general population.

Study design

Retrospective review.

Patient sample

Consecutive kidney-urinary bladder (KUB) radiographs of subjects from the past 2 years (2008–2009).

Outcome measures

Clinical demographics, number of lumbar vertebrae, L5–S1 transverse process (TP) height, and rib length.

Methods

Consecutive adult KUB studies of adult subjects were queried with clear visibility of the last rib’s vertebral body articulation, all lumbar TPs, and complete sacral wings. Exclusion criteria consisted of any radiologic evidence of previous lumbosacral surgery that would obstruct our measurements. A total of 1,100 abdominal films were reviewed, and 211 were identified as being adequate for the measurement of the desired parameters.

Results

Two hundred eleven subjects were identified as eligible for the study, and 75 (35.6%) were classified as positive for a transitional lumbosacral vertebra. The most common anatomical variant was the Castellvi Type IA (14.7%). The average age at the time of the KUB study was 59.8 years (18–95 years). One hundred ninety-seven subjects (93.4%) presented five lumbar (nonribbed) vertebrae, and only 14 (6.6%) had six lumbar vertebrae.

Conclusions

The significance of lumbosacral transitional level changes to the establishment of pain, degenerative changes, stenosis, and disc disease have been well documented in symptomatic patients. Although LSTV’s role in low back pain remains controversial, our study has shown that, when the same criteria are used for classification, prevalence among the general population and symptomatic patients may be similar.     

中老年腰椎间盘退变程度与椎旁肌退变及维生素D水平的相关性研究

目的:研究腰椎间盘退变程度与椎旁肌群退变及血清维生素D水平之间的关系。方法 :回顾性分析我院中老年腰椎间盘退变患者150例,其中女性105例,男性45例,年龄41～93(67.0±10.1)岁,所有患者行腰椎MRI检查和血清维生素D水平测定,按Pfirrmann标准,通过对髓核结构、髓核信号强度、髓核与纤维环界限及椎间盘高度等评估,对腰椎间盘退变程度分级,并根据Pfirrmann等级进行分组,纳入病例中无Ⅰ级患者,Ⅱ～Ⅴ级病例数分别为:L4/5节段,n=17、59、60及14;L5/S1节段,n=22、46、55及27。在MRI T2加权像上测量L4/5及L5/S1节段椎旁肌群(腰肌、竖脊肌及多裂肌)的标准横截面积值。根据Goutallier分级,通过评估椎旁肌脂肪浸润量多少,对椎旁肌脂肪浸润程度分级。根据内分泌学会临床实践指南将血清维生素D水平分为正常(30ng/ml)、不足(20～30ng/ml)及缺乏(20ng/ml)。分类数据的分析通过秩和检验,定量数据的分析通过单因素方差分析或Kruskal-Wallis检验,变量间相关性分析通过Spearman相关系数。结果:L4/5节段腰肌、竖脊肌及多裂肌的横截面积与腰椎间盘退变程度呈负相关(r=-0.294、-0.250及-0.182);L5/S1节段腰肌及多裂肌的横截面积与腰椎间盘退变程度呈负相关(r=-0.344及-0.346)。竖脊肌及多裂肌的脂肪浸润程度与腰椎间盘退变程度具有相关性(L4/5节段:r=0.174及0.188;L5/S1节段:r=0.193及0.283)。腰椎间盘退变分级Ⅲ～Ⅴ级患者中维生素D缺乏者与Ⅱ级患者比较,所占比例更高(Ⅱ～Ⅴ级:L4/5,47.06%、59.32%、60.00%及57.14%;L5/S1,45.45%、58.70%、56.36%及70.37%)。维生素D不足或缺乏者与正常者比较,竖脊肌及多裂肌的脂肪浸润Goutallier 2～4级所占比例更高。98%以上腰肌无或仅轻度脂肪浸润,几乎不受腰椎间盘退变程度及维生素D水平的影响。结论:椎旁肌横截面积随腰椎间盘退变程度加重而缩小,竖脊肌及多裂肌的脂肪浸润程度与腰椎间盘退变程度存在相关性。腰椎间盘退变程度较重者,维生素D缺乏的可能性更大。而维生素D缺乏者,竖脊肌及多裂肌的脂肪浸润程度可能更重。     

导航辅助腰椎椎弓根螺钉置入的误差分析

目的：探讨导航辅助腰椎椎弓根螺钉置入的准确性和误差产生的原因。方法：16例腰椎疾病的患者，在导航辅助下置人76枚椎弓根螺钉，手术后行X线和CT检查，在矢状位测量螺钉与椎弓根上缘的相对位置、与椎体上缘的角度；横断位测量螺钉与椎弓根内壁的相对位置、与椎体中线的角度。并与手术导航图像的对应数值进行统计学比较。结果：有2枚螺钉偏头侧出椎弓根，术中纠正，1枚螺钉造成椎弓根外壁缺损而被取出，2枚螺钉偏外侧出椎弓根。其余螺钉手术后CT与手术中导航图像显示的位置角度比较没有显著性差异。导航可能产生两种偏差，一种是因为椎体之间的距离缩短，常见于腰椎骨折和腰椎不稳定的患者，手术过程中腰椎前凸加大，螺钉出椎弓根上缘或下缘；另一种是扩椎弓根时图像晃动，或者开路锥在椎弓根内调整位置时产生的虚假图像误导手术者判断错误。结论：在使用导航过程中要采取措施避免腰椎的前凸加大，根据静止的图像做出判断，以减小误差。     

In situ images of the thoracic paravertebral space

BACKGROUND AND OBJECTIVES: In situ knowledge about the anatomic structures and the path of a needle percutaneously placed into the paravertebral space is an area that continues to be investigated. We describe an endoscopic technique that permits imaging of the contents and boundaries of the thoracic paravertebral space in cadavers. TECHNIQUE: A 43-year-old, 157-cm, 45-kg unembalmed female cadaver was placed in the prone position. Using a 2.3-mm diameter, 0 degree optical angle, fiberoptic ankle arthroscopy scope, trocar, introducer, and light source, thoracic paravertebral blocks were performed. To produce quality images, the trocar was advanced the length of the shaft, approximately 8 cm. The arthroscopy scope was then exchanged with the introducer. The trocar and arthroscopy scope were then gradually withdrawn posterior. RESULTS: Representative images that show the anatomic pathway of a needle as it would be directed into the paravertebral space as well as the boundaries of the thoracic paravertebral space were obtained. These included the costotransverse ligament, the spinal nerve, and the parietal and visceral pleura. CONCLUSIONS: The images help show the relationship of structures that are encountered during a paravertebral block. This new technique may be helpful in examining the spread of local anesthetic using dye or imaging the location of continuous catheters without having to dissect the insertion area.