The value of MRI compared to conventional radiography in analysing morphologic changes in the spine in axial spondyloarthritis

Background Imaging of morphologic changes in the vertebral spine in axial spondyloarthritis (SpA) is routinely performed with conventional radiography limited by superposition in the thoracic segments and radiation exposure. The objective was to assess the reliability of MRI compared to conventional radiography in depicting morphologic vertebral lesions in patients with axial SpA. Forty patients diagnosed with axial SpA were included in this cross-sectional study. Patients underwent MRI of the whole spine with T1-weighted and TIRM sequences in the sagittal plane and conventional radiography of the cervical and lumbar spine in lateral projections. Morphologic changes (syndesmophytes and erosions) in the anterior vertebral endplates on MRI and conventional radiography were independently evaluated by two radiologists. Inter-modality and interobserver agreement were calculated using Cohen’s Kappa. Results Inter-modality agreement was low for cervical and lumbar syndesmophytes and erosions (κ ≤ 0.2 ± 0.07–0.1). Interobserver agreement on conventional radiography was highest for cervical and lumbar anterior syndesmophytes/bridging (κ = 0.92 ± 0.02–0.03). Syndesmophytes in thoracic anterior vertebral units were the most frequent MRI finding with a high interobserver agreement (κ = 0.83 ± 0.05). Conclusions In imaging morphologic changes in the spine in patients with axial SpA, MRI was shown to be not an equivalent substitute but a complementary imaging modality to conventional radiography. Conventional radiography seems superior to depict morphologic cervical and lumbar vertebral changes compared to MRI, whereas MRI may visualise morphologic lesions in the thoracic spine.

Ex vivo Evaluation of the Dynamic Morphometry of the Caudal Cervical Intervertebral Disc Spaces of Small Dogs and Cats

The objective of this study was to provide a morphometric description of the caudal cervical intervertebral disc (IVD) spaces of small-breed dogs and cats. Specimens consisting of C4 through C7 from five small-breed dogs and six cats were positioned in neutral, flexion, extension, and lateral bending positions; and CT images were acquired. Height and width of the cranial and caudal vertebral endplates (VEPs), angle between the VEPs (IVD wedge angle), and craniocaudal distance (IVD width) between VEPs for the four loading positions were measured and compared for three segments (C4–C5, C5–C6, and C6–C7). VEP size normalized to body weight from medium-sized dogs was retrieved from a previous study and compared with data from small dogs and cats. A linear mixed model was used to compare outcome measures. Significance was set to p < 0.05. VEP size normalized to body weight was the largest in small dogs compared with cats (p = 0.0422) and medium-sized dogs (p = 0.0064). Cats and medium-sized dogs were similar (p = 0.2763) in this regard. Flexion and extension induced a reduction of IVD width in the ventral portion of the IVD and the area of the nucleus. The dorsal part of the IVD remained unchanged throughout loading conditions. Unique morphometric characteristics of the caudal cervical IVD space of small dogs and cats were detected that are different from those described in sizes of dogs (medium-sized) typically affected by caudal cervical spondylomyelopathy (CSM). These findings may help to understand the different pathomechanisms in cervical spinal disease between small- and medium-sized dogs, including caudal CSM.

The aiming device for cervical distractor pin insertion: a proof-of-concept, feasibility study

Background Restoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to perform a proof-of-concept, feasibility study to evaluate the effectiveness of a pin insertion aiming device for vertebral distraction pin insertion. Methods A Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging. Results The average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred. Conclusion The novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

Iatrogenic postoperative spondylodiscitis attributed to Burkholderia cepacia infection in an immunocompetent patient

Background: Pyogenic spondylodiscitis (PS) is a rare infection involving the intervertebral disk space, adjacent vertebral endplates, and vertebral bodies. PS occurs in the elderly and immunocompromised patients, and is an uncommon cause of initial and/or postoperative PS. There are only seven cases involving this organism reported in literature. Case Description: Here, we present a 35-year-old male who following a lumbar discectomy developed a postoperative iatrogenic PS uniquely attributed to Burkholderia cepacia. The patient was successfully managed with postoperative surgical debridement and antibiotic therapy. Conclusion: Rarely, B. cepacia may be the offending organism resulting in a postoperative lumbar PS.

Basivertebral nerve block during vertebral augmentation: An alternative approach to intraprocedural pain management.

Vertebral compression fractures secondary to osteoporosis can be treated with vertebral augmentation. Since intraprocedural pain is common during vertebral body endplate manipulation, these procedures are often carried out using conscious sedation or general anesthesia. Research has shown that the vertebral endplates are innervated by the basivertebral nerve, which has been successfully targeted via radiofrequency ablation to treat chronic vertebrogenic lower back pain. With this physiology in mind, we treated ten patients with vertebral compression using intraosseous basivertebral nerve block as the primary intraprocedural analgesia. In this case series, we describe our successful experience with this novel approach.

Scheuermann Kyphosis for dummies

Scheuermann kyphosis debuts in young adolescents and it is defined as a fixed hyperkyphosis >40º Cobb, with associated anterior wedging of vertebral endplates of >5º in three or more adjacent vertebrae. It is thought to be caused by mechanical stress on structurally deficitary vertebral endplates. For its diagnosis, clinical history and plain radiographs are used, but also MRI when there is neurological affection. Treatment depends on the severity of the curve: those <60º can be treated orthopedically with Milwaukee bracing in combination with rehabilitation treatment (stretching or muscle strengthening) and postural hygiene. If >70º, surgical treatment is indicated using a posterior-only approach, as it reduces de apparition of complications when compared with anterior and combined approach. Vertebral osteotomies will be made depending on the DAR. We will use pedicular screws and bars, and transverse hooks to end instrumentation, as we attach distally the SSV and proximally the first kyphotic vertebra, to avoid revision surgery. Among the complications (14%) we find surgical site infection (up to 10%), neurological injury (8%), or pulmonary complications derived from anterior approach (20%)

The Aiming Device for Cervical Distractor Pin Insertion: A Developmental and Experimental Study

Background: Restoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to evaluate the effectiveness of pin insertion aiming device for vertebral distraction pin insertion.Methods: A Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging.Results: The average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred.Conclusion: The novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

Metastatic Adenocarcinoma of the Lung Mimicking Spinal Tuberculosis

Clinically, it is sometimes difficult to distinguish an infection of the spine from a metastasis. Spinal tuberculosis is common according to its endemic region and adenocarcinoma of the lung is also rising in the incidence worldwide. Similar presentations, with unknown primary, clinical findings and hematological investigations rarely conclude a true diagnosis. Radiologically, the hallmark of spinal infection is erosion of adjacent vertebral endplates and narrowing of the disc space with or without a paravertebral shadow. Metastasis typically does not involve the disc space with erosion of the adjacent vertebral endplates. It usually presents as a lytic/sclerotic lesion in the vertebral body or “winkle owl” sign. These distinguishing features of infection versus metastasis are not certainties. Biopsy is mandatory whenever in doubt or patient is not responded with provisional treatment. The author presents a case with so-called radiological features of spinal tuberculosis infection, which turns out to be a metastatic adenocarcinoma of the lung.