Pelvic pain in Maigne’s syndrome—a multi-segmental approach

Background Maigne’s syndrome is a poorly understood condition that affects the thoracolumbar junction. The symptoms can range from pain in the low back, pelvis, hip, lower abdomen, and groin. These symptoms can have bio-mechanical and neurophysiological attributions due to the complexity of spinal mechanics. Thoraco-lumbar junction (T12-L1) is a transitional zone with a higher degree of mean angular motion and a mean translation motion than T10-T11 and T11-T12. This higher degree of translational and rotation mobility predisposes these segments to a higher degree of stress, making them more prone to biomechanical faults such as dysfunctions and positional faults. These altered static and dynamic mechanics can create a cascade of problems along the biomechanical chain. The co-existence of thoracolumbar junction problems with pelvic pain and dysfunctions strengthens the idea of regional interdependence. Case presentation The patient is a 44-year-old Caucasian male who reported pain in the low back with symptoms radiating to the right hip, iliac region, lower abdomen, and gluteal region. The patient tested positive for Sacroiliac joint dysfunction with both Laslett’s cluster testing and palpatory sacroiliac examination. In addition, the segmental examination showed restriction in thoracolumbar junction with positive skin rolling test and hypomobility in manual segmental testing. Thus, the manual therapy treatment targeted the thoracolumbar junction and sacroiliac joint to address the underlying biomechanical dysfunctions. Conclusions The manual therapy targeting both sacroiliac and thoracolumbar spine can improve pelvic and thoracic spine mobility. In addition, therapeutic exercises can focus on enhancing anterior and posterior chain force generation capacity. This combined approach helped improve functional outcomes with a significant decrease in the Modified Oswestry Disability index and significant improvement on Visual analog scale.

Texture Analysis Using CT and Chemical Shift Encoding-Based Water-Fat MRI Can Improve Differentiation Between Patients With and Without Osteoporotic Vertebral Fractures

PurposeOsteoporosis is a highly prevalent skeletal disease that frequently entails vertebral fractures. Areal bone mineral density (BMD) derived from dual-energy X-ray absorptiometry (DXA) is the reference standard, but has well-known limitations. Texture analysis can provide surrogate markers of tissue microstructure based on computed tomography (CT) or magnetic resonance imaging (MRI) data of the spine, thus potentially improving fracture risk estimation beyond areal BMD. However, it is largely unknown whether MRI-derived texture analysis can predict volumetric BMD (vBMD), or whether a model incorporating texture analysis based on CT and MRI may be capable of differentiating between patients with and without osteoporotic vertebral fractures.Materials and MethodsTwenty-six patients (15 females, median age: 73 years, 11 patients showing at least one osteoporotic vertebral fracture) who had CT and 3-Tesla chemical shift encoding-based water-fat MRI (CSE-MRI) available were analyzed. In total, 171 vertebral bodies of the thoracolumbar spine were segmented using an automatic convolutional neural network (CNN)-based framework, followed by extraction of integral and trabecular vBMD using CT data. For CSE-MRI, manual segmentation of vertebral bodies and consecutive extraction of the mean proton density fat fraction (PDFF) and T2* was performed. First-order, second-order, and higher-order texture features were derived from texture analysis using CT and CSE-MRI data. Stepwise multivariate linear regression models were computed using integral vBMD and fracture status as dependent variables.ResultsPatients with osteoporotic vertebral fractures showed significantly lower integral and trabecular vBMD when compared to patients without fractures (p<0.001). For the model with integral vBMD as the dependent variable, T2* combined with three PDFF-based texture features explained 40% of the variance (adjusted R2[Ra2] = 0.40; p<0.001). Furthermore, regarding the differentiation between patients with and without osteoporotic vertebral fractures, a model including texture features from CT and CSE-MRI data showed better performance than a model based on integral vBMD and PDFF only (Ra2 = 0.47 vs. Ra2 = 0.81; included texture features in the final model: integral vBMD, CT_Short-run_emphasis, CT_Varianceglobal, and PDFF_Variance).ConclusionUsing texture analysis for spine CT and CSE-MRI can facilitate the differentiation between patients with and without osteoporotic vertebral fractures, implicating that future fracture prediction in osteoporosis may be improved.

Classification and Radiological Diagnosis of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

The aim of this review to determine recommendations for classification and radiological diagnosis of thoracolumbar spine fractures. Recommendation was made through a literature review of the last 10 years. The statements created by the authors were discussed and voted on during 2 consensus meetings organized by the WFNS (World Federation Neurosurgical Societies) Spine Committee. The literature review was yielded 256 abstracts, of which 32 were chosen for full-text analysis. Thirteen papers evaluated the reliability of a classification system by our expert members and were also chosen in this guideline analysis. This literature review-based recommendation provides the classification and radiologic diagnosis in thoracolumbar spine fractures that can elucidate the management decision-making in clinical practice.

Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

To formulate the specific guidelines for the recommendation of thoracolumbar fracture regarding surgical techniques and nonfusion surgery. WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meeting. For nonfusion surgery and thoracolumbar fracture, a systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020. The search was further refined by excluding the articles which were duplicate, not in English or were based on animal or cadaveric subjects. After thorough shortlisting, only 50 articles were selected for full review in this consensus meeting. To generate a consensus, the levels of agreement or disagreement on each item were voted independently in a blind fashion through a Likert-type scale from 1 to 5. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided. A magnitude of prospective papers were analyzed to formulate consensus on various surgical techniques that can be employed to address different types of thoracolumbar fractures. Surgical treatment of thoracolumbar fractures can be a better option over the nonoperative approach, especially for those who cannot tolerate months in an orthosis or cast, such as those with multiple extremity injuries, skin lesions, obesity, and so forth. It generally allows early mobilization, less hospital stay, reduced pulmonary complications, and better correction of sagittal balance. Current available literature fails to demonstrate any statistically significant benefit of fusion surgery over nonfusion in thoracolumbar fractures.

Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The incidence of thoracolumbar spine fractures is increasing because of low-velocity falls in the elderly population. The main reasons are falls and traffic accidents. Learning the regional differences and some special forms of trauma such as extreme sports, war, and gunshot injuries will help the prevention of the thoracolumbar spine fractures.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

Kyphosis After Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar fractures change the biomechanics of the spine. Load distribution causes kyphosis by the time. Treatment of posttraumatic kyphosis is still controversial. We reviewed the literature between 2010 and 2020 using a search with keywords “thoracolumbar fracture and kyphosis.” We removed osteoporotic fractures, ankylosing spondylitis fractures, non-English language papers, case reports, and low-quality case series. Up-to-date information on posttraumatic kyphosis management was reviewed to reach an agreement in a consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The first meeting was conducted in Peshawar in December 2019 with WFNS Spine Committee members’ presence and participation. The second meeting was a virtual meeting via the internet on June 12, 2020. We utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized 42 papers on posttraumatic kyphosis. Surgical treatment of thoracolumbar kyphosis due to unstable burst fractures can be done via a posterior only approach. Less blood loss and reduced surgery time are the main advantages of posterior surgery. Kyphosis angle for surgical decision and fusion levels are controversial. However, global sagittal balance should be taken into consideration for the segment that has to be included. Adding an intermediate screw at the fractured level strengthens the construct.