Correlation of palpation versus ultrasound-assisted approach for locating the level of lumbar puncture used for subarachnoid block in elective cesarean delivery

Aims: To correlate the level of lumbar puncture used for subarachnoid block in parturient undergoing elective cesarean delivery between palpation and ultrasound method; and to find its accuracy. Methods: This is an observational study, conducted in 314 parturient undergoing elective caesarean delivery under spinal anesthesia over the period of three months at Paropakar Maternity and Women's Hospital Kathmandu. The interspinous space identified by palpation method on lateral position for subarachnoid block and later the site confirmed by ultrasound. Results: In this study, intervertebral space identified by palpation was matched in 38.1% (i.e. 107 in 281 patients) when assessed with ultrasound (USG). In 166 (59.1%) patients, skin puncture level was determined by palpation was found to be one intervertebral space cephalic. In eight (2.8%) patients, one intervertebral space caudal while assed with USG. The correlation between intervertebral space determined by palpation and by ultrasonography was poor (correlation coefficient r=0.288).The kappa was 0.293±0.015. Conclusions: The level of lumbar puncture used for subarachnoid block in elective cesarean delivery by palpation method is poorly correlated (38.1%) with ultrasonographic identification of corresponding interspinous level.

Acute Attack of Pseudogout with the Wide Lesion in Lumbar Spondylolytic Spondylolisthesis

Objective. To report a rare case of an acute attack of calcium pyrophosphate dihydrate (CPPD) deposition disease in a patient with lumbar spondylolytic spondylolisthesis, which demonstrated widespread lesion with neurological deficit. Methods. An 86-year-old woman presented with high fever and bilateral neurological deficit of the lower extremities. Results. CRP was elevated (20.9 mg/dl). Plain radiographs and computed tomography images showed bilateral L4 spondylolytic spondylolisthesis. Sagittal magnetic resonance (MR) images revealed effusion at the L3-4 interspinous space, and a gadolinium- (GD-) enhanced epidural mass was observed at the level of L4 vertebral body. Axial MR images showed an intra- or epidural lesion at L2-3. Moreover, epidural GD-enhanced masses compressed the dural sac in the shape of a cross at the L3-4 and L4-5 segments. The patient was suspected of having pyogenic arthritis of the lumbar spine in initial diagnosis. A total of 1.2 ml of fluid with a murky, pus-like synovial effusion was aspirated from the L3-4 interspinous space under the fluoroscopic image. Smear speculum of synovial fluid tested negative for bacteria and fungi; however, a number of crystals were seen. Based on the result of smear speculum, we suspected the pathology as crystal deposition disease. Based on polarized light microscopy, which revealed monocle or triclinic intracellular crystals with a positive birefringence, the patient was diagnosed with pseudogout of the lumbar spine. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered by intravenous drip injection for 3 days, and local and systemic inflammatory signs, as well as neurological deficits, dramatically improved. Conclusions. We encountered the rare case of an acute attack of pseudogout with the wide lesion in the lumbar spondylolytic spondylolisthesis. Multiple culture of the effusion provided a definitive diagnosis, which allowed for appropriate, minimally invasive treatment for 8 weeks of NSAID administration that provided the satisfactory recovery from the symptoms.

Facet joint degeneration adversely affects ultrasound imaging of the lumbar spine

Aim: Ultrasound of neuraxis can be used to identify the best possible inter-spinous space to perform neuraxial block. The aim of this study was to assess the anatomical correlation between neuraxial ultrasound and magnetic resonance imaging (MRI).Material and method: Twenty-one patients who underwent MRI of the lumbar spine had ultrasound of lumbar neuraxis performed by an experienced operator. Each lumbar interspinous space was graded on ultrasound as good [posteriorcomplex (ligamentum flavum and duramater) and anterior complex (posterior longitudinal ligament) visible], intermediate (either anterior complex or posterior complex visible) or poor (both anterior complex and posterior complex not visible) in both the transverse median (TM) and paramedian sagittal oblique (PSO) plane. Pre-determined MRI parameters were measured by a radiologist blinded to sonographic findings at each inter-spinal level.Results: Seventy-eight lumbar interspinous spaces were evaluated. There was a significant association (p<0.004) between the facet joint degeneration on MRI and the poor ultrasound view in the transverse median (TM) group. The odds of obtaining a poor view in TM plane was 7 times higher (95% CI 1.7-28.9, p=0.007) in the presence of facet joint degeneration. None of the other variables had a significant association with a poor neuraxial view in the TM plane. Poor views in the parasagittal oblique (PSO) plane did not correlate with any of the variables measured on MRI.Conclusion: Facet joint degeneration is a major contributing factor to poor neuraxial ultrasound views in the TM plane.

Incidence of heterotopic ossification after implantation of interspinous process devices

Object This study aimed to investigate the incidence rate of heterotopic ossification (HO) after implantation of Coflex interspinous devices. Possible risk factors associated with HO were evaluated. Methods The authors retrospectively analyzed patients who had undergone single-level (L4–5) implantation of a Coflex device for the treatment of lumbar spinal stenosis. Patient data recorded were age, sex, height, weight, body mass index, smoking habits, and surgical time. Heterotopic ossification was identified through lumbar anteroposterior and lateral view radiographs. The authors developed a simple classification for defining HO and compared HO-positive and HO-negative cases to identify possible risk factors. Results Among 32 patients with follow-up times of 24–57 months, HO was detectable in 26 (81.2%). Among these 26 patients, HO was in the lateral space of the spinous process but not in the interspinous space in 8, HO was in the interspinous space but did not bridge the adjacent spinous process in 16, and interspinous fusion occurred at the level of the device in 2. Occurrence of HO was not associated with patient age, sex, height, weight, body mass index, smoking habits, or surgical time. Conclusions A high incidence of HO has been detected after implantation of Coflex devices. Clinicians should be aware of this possible outcome, and more studies should be conducted to clarify the clinical effects of HO.

SURGICAL TREATMENT OF LUMBAR SEGMENT DISEASE WITH INTERSPINOUS IMPLANT: REVIEW

Interspinous implants (ISP) represent a contemporary non-fusion surgical option in the treatment of lumbar segment disease. Several devices have been developed within the last two decades and have been variously supported by investigations into their clinical and biomechanical efficacy. Spinal stenosis and facet arthropathy are reported as the primary clinical indications for their use, with degenerative disc disease and segmental instability recently extending their application. The principle common to all interspinous systems is an induced distraction of the interspinous space, resulting in reduced approximation of pain-sensitive and space-occupying tissue. Collectively, these devices are considered to prevent adjacent segment overload by restoring physiologic load transmission. This review article summarizes existing published literature, describes four different interspinous implants — the DIAM, Wallis, X-Stop and Coflex systems, and outlines clinical trials in progress. The design and surgical technique characteristics, mechanism of action, and clinical indications for interspinous implants are reviewed. Recommendations for future research of interspinous implants in the treatment of lumbar segment disease are made.