Lateral fusion

Sacroiliac joint pain and dysfunction has increasingly been identified as an important pain generator in patients with chronic back pain or failed back surgery syndrome, and it is estimated to account for 15% to 30% of low back pain cases. Historically, fusion of the joint has been performed with an open posterior or posterolateral approach. Minimally invasive surgical (MIS) approaches were introduced in 2008, and since that time MIS posterior and lateral approaches have become common. Numerous medical device companies have marketed MIS systems, and evidence of their safety and efficacy is mounting. This chapter will detail lateral MIS approaches using fluoroscopic and navigation system guidance, as well as the posterolateral open approach, also known as the modified Smith-Petersen approach. Evidence for safety and efficacy of lateral sacroiliac joint fusion will also be discussed.

Uterine Didelphys with Transverse Vaginal Septum – A Complex rare Müllerian anomaly

During the development of the female genital tract, any insult to the normal development process results in a set of intriguing abnormalities known as Müllerian duct abnormalities. The uterine didelphys is the second least common type of anomaly among these, which may commonly be associated with a longitudinal vaginal septum (lateral fusion defect). However uterine didelphys along with a transverse vaginal septum (lateral fusion plus resorption defect) is a very rare finding and to the best of our knowledge, thecase that we hereby report is the second one in literature.A 16-year-old unmarried girl presented with primary amenorrhoea and cyclical pain for 18months.On clinical examination and imaging, a case of uterine didelphys and transverse vaginal septum was found. Her urinary tract was normalon USG and MRI evaluation. Excision of the septum was done by abdomino-vaginal approach. The patient was discharged well.We conclude that a patient presenting with primary amenorrhea especially with cyclical dysmenorrhea with a transverse vaginal septum on examination should be thoroughly investigated for associated upper genital tract abnormalities as the treatment strategy and prognosis is largely dependent on the correct classification of the anomaly.

Unicornuate uterus: case reports of heterogenous presentations challenging clinical diagnosis and management

Unicornuate uterus is an anomaly arising from defective lateral fusion of incompletely developed mullerian duct or paramesonephric duct with the contralateral duct. Pregnancy in non-communicating rudimentary horn can result in I and II trimester pregnancy losses along with maternal morbidity and mortality. Here we describe three such cases of unicornuate uterus with non-communicating rudimentary horn pregnancy, who presented to our hospital with pain in lower abdomen. Two of them with II trimester pregnancy landed in haemorrhagic shock owing to rupture of pregnant horn, though were revived by immediate intervention. Third patient who came with a definitive diagnosis of I trimester rudimentary horn pregnancy was managed electively by hemi-hysterectomy. Rupture of pregnant uterus can occur in II trimester when associated with uterine anomaly. Early sonographic diagnosis has a major offering in workup, management and prevention of mother from grave life threatening consequences.

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review

Study Design: Systematic review. Objective: Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression. Methods: A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance. Results: A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant ( P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant ( P = .053). Conclusions: Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

Nanoribbons or Weakly Connected Acenes? The Influence of Pyrene Insertion on Linearly Extended Ring Systems

Derived from the lateral fusion of benzene rings, acenes are a class of π-conjugated molecules containing a single aromatic sextet, where system size is inversely correlated with chemical stability. In...

Effects of Netarsudil on Actin-Driven Cellular Functions in Normal and Glaucomatous Trabecular Meshwork Cells: A Live Imaging Study

The actin cytoskeleton of trabecular meshwork (TM) cells is a therapeutic target for lowering intraocular pressure (IOP) in glaucoma patients. Netarsudil (the active ingredient in RhopressaTM) is a Rho-associated protein kinase inhibitor that induces disassembly of actin stress fibers. Here, we used live cell imaging of SiR-actin-labeled normal (NTM) and glaucomatous TM (GTM) cells to investigate actin dynamics during actin-driven biological processes with and without netarsudil treatment. Actin stress fibers were thicker in GTM than NTM cells and took longer (>120 min) to disassemble following addition of 1 µM netarsudil. Actin-rich extracellular vesicles (EVs) were derived by two mechanisms: exocytosis of intracellular-derived vesicles, and cleavage of filopodial tips, which detached the filopodia from the substratum, allowing them to retract to the cell body. While some phagocytosis was noted in untreated TM cells, netarsudil potently stimulated phagocytic uptake of EVs. Netarsudil treatment induced lateral fusion of tunneling nanotubes (TNTs) that connected adjacent TM cells; TNTs are important for TM cellular communication. Together, our results suggest that netarsudil may clear outflow channels in TM tissue by inducing phagocytosis and/or by modulating TM communication via EVs and TNTs. These cellular functions likely work together to regulate IOP in normal and glaucomatous TM.

Extreme Lateral Interbody Fusion for Thoracic and Thoracolumbar Disease: The Diaphragm Dilemma

Study Design: Retrospective cohort study. Objective: Complication profiles for lateral approaches to the spine are well established. However, the influence of level of surgery on complication rates and subtypes are less well established. To determine risk factors for complications as determined by level and surgery type in patients undergoing a lateral (retroperitoneal or retropleural approach) to the thoracolumbar spine. Methods: All adult patients undergoing a lateral thoracolumbar fusion with or without posterior instrumentation performed at a single institution were identified. Primary outcomes assessed were presence of complication, complication subtype, and need for reoperation. The primary independent variables were spinal level (thoracic, thoracolumbar, or lumbar) and type of surgery (discectomy or corpectomy). Categorical outcomes were compared using chi-square test. Unadjusted and adjusted odds ratios for corpectomy status were calculated to determine risk of complication by level. P < .05 was considered statistically significant. Results: A total of 165 patients aged 18 to 75 years were identified as having undergone a lateral fusion. Complication rates were 28.6%, 36.4%, and 11% for thoracic, thoracolumbar, and lumbar lateral approach fusions, respectively. Under univariate analysis, patients undergoing lateral approach in the thoracic spine group had significantly higher rates of postoperative complications than those in the lumbar group ( P = .005). After adjusting for corpectomy status, there was no difference in complication rates. Conclusions: Lateral (retroperitoneal or retropleural) approaches to the thoracic and thoracolumbar spine may be used with complication rates comparable to well-established lumbar approaches. Extent of surgery (corpectomy vs discectomy) rather than level of surgery may represent the primary driver of complications.

OHVIRA Syndrome: A Case Report

OHVIRA syndrome or Herlyn-Werner-Wunderlich syndrome is a rare congenital anomaly of female urogenital tract which is represented by the triad of uterine didelphys, obstructed hemivagina and ipsilateral renal agenesis. This rare variant of Müllerian duct anomalies represent failure of vertical and the lateral fusion of Müllerian ducts around 9 weeks of gestation. OHVIRA syndrome comprises about 2-3% of Müllerian abnormalities. A 13 years old girl got admission in FMCH on 15.3.2018 with lower abdominal pain and acute retention of urine. Her menarche was established 6 months back with regular cycle and associated with dysmenorrhoea. Imaging studies revealed uterine didelphys, highly dilated cervix with hematocolpos and absence of right kidney. The vaginal septum was excised. The patient recovered fully and was under follow up for 6 months. There was no evidence of further outflow tract obstruction. Faridpur Med. Coll. J. Jan 2019;14(1): 54-56

Immunohistochemical Examination of Trophoblast Syncytialization during Early Placentation in Sheep

During the peri-implantation period, multinucleated syncytia are formed in the sheep placenta. For over 20 years the scientific consensus has been that during trophoblast syncytialization in sheep, binucleate trophoblast giant cells (BNCs) differentiate from mononuclear trophoblast cells, and individual BNCs fuse with individual luminal epithelial (LE) cells to form trinucleate cells. These trophoblast–LE syncytial plaques then grow through continued BNC migration and fusion. Therefore, LE cells are thought to be incorporated into syncytial plaques. However, these ideas were based on electron microscopy studies, without benefit of molecular markers for BNC and LE cells to support conclusions. The aim of this study was to observe interactions between BNCs and uterine LE cells using immunohistochemical localization for molecular markers for BNCs and uterine LE cells. We performed immunofluorescence staining, laser capture microdissection, and TUNEL staining on the uterine–placental tissues of sheep during early placentation. We observed: (1) syncytial cells containing more than two nuclei within the trophoblast cell layer; (2) depolarized LE cells that express caspase 3 and stain positively for TUNEL; (3) engulfment of caspase 3-positive LE cells by trophoblast giant cells (TGCs) and empty spaces within the LE layer at sites of implantation; (4) rapid enlargement of syncytial plaques; and (5) E-cadherin and TUNEL-positive cells within the uterine stroma underlying degenerating LE was coincident with accumulation of CD45-positive cells at these sites. These data suggest that during early placentation: (1) fusion between trophoblasts is not limited to the formation of BNCs, and the term ‘trophoblast giant cell (TGC)’ may be appropriate; (2) LE cells undergo apoptosis; (3) apoptotic LE cells are eliminated by TGCs; (4) fusion is not limited to the incorporation of new BNCs but involves the lateral fusion between growing syncytial plaques; and (5) TGCs carry apoptotic LE cells away from the uterine–placental interface for elimination by immune cells within the stroma. These data indicate that uterine LE cells are not incorporated into syncytial plaques, but are engulfed and eliminated, and that early placentation in sheep is more similar to early placentation in humans than is currently understood in that both develop mononucleated cytotrophoblast and multinucleated syncytiotrophoblast layers of entirely placental origin. The elimination of LE cells by sheep TGCs might provide insights into elimination and penetration of LE cells during human embryo implantation.