Unusual presentation of vertebral endplate Modic changes in congenital scoliosis associated with pain: a report of two cases

Congenital scoliosis is not normally associated with pain in young children. We are presenting two cases of young patients with congenital scoliosis and moderate to severe pain. There were no spinal cord abnormalities found in these patients. The magnetic resonance imaging and CT scan revealed disc degeneration with Modic changes at the apex of the congenital scoliosis. We hypothesized that the mechanical instability resulting from poor spinal element formations associated with congenital scoliosis was responsible for causing the disc degeneration and endplate changes. Modic changes have been reported to be associated with pain in degenerative conditions of the spine. Both patients underwent a posterior spinal fusion and instrumentation, which relieved their pain immediately.     

Eradication of Missing Liver Metastases After Fiducial Placement

Background

The risk of colorectal liver metastases (CLM) disappearing on cross-sectional imaging has increased with advances in preoperative chemotherapy, but <50 % of disappearing CLM demonstrate complete pathological response.

Objective

The aim of this study was to evaluate the role of fiducial marker placement before potentially curative treatment of CLM at risk of disappearing with chemotherapy.

Methods

All consecutive patients who underwent fiducial placement for tracking of CLM at a tertiary center were reviewed.

Results

Among 1377 patients undergoing CLM resection between 2005 and 2015, 35 patients underwent fiducial placement. Three patients were excluded due to disease progression. The study population comprised 32 patients who underwent fiducial placement in 41 CLM. Among the 41 marked CLM, 34 (83 %) were located >10 mm deep in the liver parenchyma, 25 (61 %) were in the right liver, and median size was 12 mm (range, 6–20 mm). No complication occurred after fiducial placement. After chemotherapy, 19 (46 %) of the 41 marked metastases disappeared on cross-sectional imaging. All fiducial-tracked CLM were treated with resection (n?=?31) or ablation (n?=?10). After median follow-up of 14 months (range, 0–64 months), no local recurrences were observed.

Conclusion

Fiducial placement represents a safe procedure that facilitates accurate localization for resection or ablation of small CLM at risk of disappearing with chemotherapy.

     

Fibrotomy with diode laser (980 nm) and habit correlation in oral submucous fibrosis: a report of 30 cases

To evaluate the efficacy of laser fibrotomy in patients with oral submucous fibrosis (OSMF) and also to correlate the habit variables causing OSMF. Thirty patients diagnosed clinically and histopathologically with OSMF were included in the study. Laser fibrotomy was done under local anesthesia using Zolar diode laser (980 nm frequency) at 2-W power in contact mode with fibro-optic cutting tip. The patients were advised to practice mouth-opening exercises rigorously, and topical corticosteroid was given for burning sensation and pain for 6 months. Pre- and post-treatment comparison of mouth opening, burning sensation, tongue protrusion, and cheek flexibility was analyzed after a follow-up period of 9 months. After a follow-up period of 9 months from the surgical intervention, the mean value of difference in pre- and post-treatment of VAS score, mouth opening, and tongue protrusion was found to be 3.3?±?2.1, 7.7?±?5.1, 1.6?±?2.7, and 0.38?±?0.61 respectively. Using the Wilcoxon signed rank test, all the above difference in mean was found to be significant with p value <?0.05. With above suggested significant results, lasers can provide an alternative and better means for surgical fibrotomy, relieving trismus in moderate OSMF as they are minimally invasive, cause less hemorrhage, and have faster healing and minimal surgical site scaring and relapse.     

Patient-controlled regional analgesia (PCRA) with ropivacaine after arthroscopic subacromial decompression

BACKGROUND: The aim of the study was to evaluate postoperative analgesia and safety of wound instillation of ropivacaine either by a single dose or a patient-controlled regional anaesthesia (PCRA) technique. METHODS: In 40 patients undergoing arthroscopic subacromial decompression the surgeon placed a catheter into the subacromial space at the end of the operation. In Phase I (10 patients), ropivacaine 250 mg was injected twice within 1 h. In Phase II, 30 patients were randomised into three groups: group prilocaine-ropivacaine (PR) = 20 ml of 1% prilocaine-epinephrine injected preoperatively into the subacromial bursa + 20 ml of 0.5% ropivacaine infused in the catheter postoperatively; group saline-ropivacaine (SR) = saline-epinephrine (20 ml) preoperatively + 0.5% ropivacaine as in group PR; group saline-saline (SS) = saline-epinephrine (20 ml) preoperatively + saline postoperatively. The PCRA pump was filled with local anaesthetic or saline to allow boluses of 10-ml each, maximum one bolus/h, via the catheter. Pain relief, side-effects and venous plasma concentration of ropivacaine were evaluated during a 24-h-test period. RESULTS: The free plasma concentration of ropivacaine was 0.12 + 0.041 mg l-1 in Phase I. No adverse effects were seen. In Phase II pain at rest and on movement was lower in group PR than in group SS during the first 30 min postoperatively (P < 0.05). Group PR had the lowest morphine consumption (P < 0.05). Five to seven boluses were administered via the PCRA-pump, and 20 min after administration of the study solution, pain was lower in groups PR and SR compared with group SS (P < 0.001). CONCLUSIONS: Preoperative intrabursal prilocaine with epinephrine + postoperative subacromial administration of ropivacaine by PCRA-technique provided the most effective analgesia with no major side-effects. The free plasma concentrations of ropivacaine were far below toxic concentrations.     

Optimizing Cancer Radiotherapy with 2-Deoxy-D-Glucose Dose Escalation Studies in Patients with Glioblastoma Multiforme

Background and Purpose:  

Higher rates of glucose utilization and glycolysis generally correlate with poor prognosis in several types of malignant tumors. Own earlier studies on model systems demonstrated that the nonmetabolizable glucose analog 2-deoxy-D-glucose (2-DG) could enhance the efficacy of radiotherapy in a dose-dependent manner by selectively sensitizing cancer cells while protecting normal cells. Phase I/II clinical trials indicated that the combination of 2-DG, at an oral dose of 200 mg/kg body weight (BW), with large fractions of γ-radiation was well tolerated in cerebral glioma patients. Since higher 2-DG doses are expected to improve the therapeutic gain, present studies were undertaken to examine the tolerance and safety of escalating 2-DG dose during combined treatment (2-DG + radiotherapy) in glioblastoma multiforme patients.     

Role of diffusion weighted imaging in differentiation of intracranial tuberculoma and tuberculous abscess from cysticercus granulomas-a report of more than 100 lesions

Restricted diffusion is noted in a large number of non-stroke conditions including tuberculoma. The purpose of this study was to demonstrate spectrum of diffusion weighted imaging (DWI) abnormalities in tuberculomas and tuberculous abscess and to distinguish these from degenerating neurocysticercosis. Seventy tuberculomas and tuberculous abscesses in 30 patients were categorized in three groups depending on the intensity in the core of the lesion on T2 weighted images. Mean apparent diffusion coefficient (ADC) was calculated from the core as well as from the wall of the lesions. Forty-five lesions of neurocysticercosis in different stage of evolution in 12 patients were also included for comparison. The mean ADC value from the core of the T2 hypointense lesions was significantly higher compared to the wall ((1.24+/-0.32)x10(-3) and (1.06+/-0.15)x10(-3)mm(2)/s, respectively), while mean ADC value from the core of mildly T2 hyperintense lesions was significantly lower compared to the wall ((0.80+/-0.08)x10(-3) and (1.08+/-0.13)x10(-3)mm(2)/s, respectively). Truly T2 hyperintense lesions were divided into two subgroups, tuberculomas and tuberculous abscesses; ADC values from the core and the wall of these lesions were (0.74+/-0.13)x10(-3), (0.61+/-0.08)x10(-3) and (1.03+/-0.14)x10(-3), (1.08+/-0.14)x10(-3)mm(2)/s, respectively, and was significantly lower in core as compared to the wall. However, there was no significant difference between ADC values of the tuberculous abscess and the hyperintense tuberculomas. Vesicular and degenerating stages of cysticercus cysts from the core showed ADC values of (1.66+/-0.29)x10(-3) and (1.51+/-0.23)x10(-3)mm(2)/s, respectively, and were significantly higher than the core of all groups of tuberculomas and tuberculous abscess. We conclude that addition of DWI to routine imaging protocol may help in differentiation of tuberculous lesions from degenerating cysticercus granuloma.     

Forensic considerations of missed diagnoses in trauma deaths

Injuries missed at initial diagnoses or operations have the potential to cause disastrous complications in trauma patients. Understanding the etiology of unrecognized injuries is essential in minimizing its occurrence. For this purpose, we scrutinized the treatment and the autopsy records of the trauma deaths from 2000 to 2004 to determine the frequency, body regions, severity and causes of injuries that escaped recognition during the initial assessment, primary, secondary and tertiary surveys by the clinical team in patients who died of trauma. We also examined the accuracy of the cause of death as recorded on death certificates. The frequency of unrecognized injuries was found to be 11% in all trauma deaths. Abdomen (40%) and head (29%) were the more common regions of the body where injuries were frequently missed. System related errors (68%) and patient related factors (32%) were responsible for the injury remaining unrecognized. It was concluded that the injuries may be missed at any stage of the management of patients with major trauma and repeated assessments both clinical and radiological are mandatory not only to diminish the problem but to avoid litigation as well.