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PubMed1999

[Acquired reactive perforating collagenosis in diabetes mellitus].

HISTORY AND ADMISSION FINDINGS: A 70-year-old woman with type 2B diabetes mellitus was referred to the dermatology department because of inflammatory skin changes of unknown origin over the trunk and limbs. On admission follicular and parafollicular livid-red papulae with central crusts and reddened margins were noted over the lower legs and the lumbosacral region. INVESTIGATIONS: Further physical examination revealed no additional abnormalities. Erythrocyte sedimentation rate was 41/79 mm. The day-time blood-glucose profile was raised (10.2, 12.6 and 8.6 mmol/l), as was the glycosylated haemoglobin HbA1c (9.0%). Swabs from fresh lesions gave no evidence of fungal or bacterial infection. Biopsies revealed areas of widened epidermis with central ulceration filled with fibrin, granulocytes and collagen fibres. DIAGNOSIS, TREATMENT AND COURSE: The clinical and histological findings indicated an acquired reactive perforating collagenosis (dermatosis) which should be judged in relation to the long-standing diabetes mellitus. The cutaneous changes were covered with salicylate- and steroid-containing preparations, while individual lesions were excised or removed by curettage. CONCLUSION: The condition of acquired reactive perforating collagenosis is, like Kyrle's disease (perforating follicular and parafollicular hyperkeratotic dermatosis), perforating serpiginous elastosis and perforating folliculitis classified among the perforating dermatoses. In the presence of renal failure and (or) diabetes mellitus these dermatoses must be thought of in the differential diagnosis, in addition to the more frequent pruriginous conditions, if there are corresponding skin changes.

Administration, Cutaneous↗

PubMedDate not supplied

[Characteristics in the treatment of scoliosis in muscular diseases].

INTRODUCTION: Patients suffering from the most frequent muscle disorders Duchenne muscular dystrophy (DMD) and spinal muscular atrophies (SMA), who ceased walking respectively are confined from the outset to the wheel-chair, are developing commonly a progressive scoliosis (collapsing spine) due to an increasing muscle weakness. Basing on the pelvic obliquity these scolioses are leading first of all to problems in sitting as well as difficulties in trunk and head control. Along with the increasing weakness of respiratory muscles these phenomena entail a restrictive respiratory insufficiency. CONSERVATIVE TREATMENT: An effective conservative treatment is not available for these scolioses. The use of a corset, however, can only be taken into consideration as a compromise, either for very young patients or those who refused an operation respectively who have reached an inoperable stage. The exclusive use of so-called "anatomic sitting supports" in the wheel-chair in order to treat or prevent a progressive scoliosis in DMD or SMA is absolutely to be rejected. They should only be applied for very young patients with SMA type II as a transitional solution until a corset or better an surgical stabilisation of the spine will be effected, or as a palliative measure in late stages. SURGICAL TREATMENT: Only the early as possible performed surgical stabilisation of the spine using adequate instrumentation (Luque, CD or modifications), enabling an early mobilization without corset or cast, is the most effective treatment of these scoliosis. Patients with DMD or SMA type III should be stabilized after loss of walking ability and definitive confinement to wheel-chair, if the curve is more than 20 degrees-30 degrees Cobb and progressive and forced vital capacity (FVC) is > 35%. The instrumentation should be applied between D3 or D4 and sacrum. The bony fusion mass should include the lumbar and lumbosacral region. The unfused instrumentation with the telescope-rod after Naumann is a good solution for patients with SMA type II and progressive curves already in the early childhood from ca. 5 years of age. First of all surgical spinal stabilisation improves the sitting comfort. Over and above this the improved cosmetic appearance should not be underestimated for the psychological condition of these patients. Additionally it is proved, that surgical stabilisation of the spine prolongs the life expectancy of patients with DMD. Furthermore stabilization of lung function can be achieved for both DMD and SMA patients in comparison to the natural history of these diseases. Altogether a decisive improvement of quality of life can be reached for all these patients.

Adolescent↗

PubMed1988

[Intraspinal lipoma with tethered cord syndrome in childhood].

In this article the authors report on a series of 26 children with spina bifida occulta in combination with intraspinal lipoma and clinical signs of tethered cord syndrome. The age of the children at presentation ranged from 1 month to 12 years. The typical signs and symptoms of the patients consisted of dermatological changes in the lumbosacral region, neurogenic foot deformities and genitourinary tract anomalies with disturbed bladder function. The diagnosis was confirmed by neuroradiological studies including lumbal myelography, spinal computerized tomography and only recently magnetic resonance imaging. Indications for surgery were based on the radiological evidence of intraspinal lipoma and tethered cord and especially on the clinical signs of neurological deterioration. The results of the operative treatment are presented and the role of surgery before onset of symptoms as well as during the symptom-free interval are discussed.

Child↗

PubMed1986

[Electromyographic and neurologic findings in radiologically demonstrated numerical variations in the lumbosacral transition].

Discussions have been going on since the publications of Bertolotti (1917) and Blumensaat and Clasing (1932) as to whether variations in the lumbosacral region and vertebral anomalies, which may alter the statics of the vertebral column, result in typical neurological disorders. Lange and Hipp (1962) found prolapses of lumbar disks localised in the segment above a unilateral or complete assimilation. As they lacked the possibility of an electromyographical examination, they had difficulties in correlating clinical and radiological findings. Neurological, electromyographical and radiological analysis of 20 patients (2 sacralisations, 6 unilateral assimilations, and 12 cases of lumbalisation) revealed: good correlation between clinical and electromyographical findings. In six cases only clinical and electromyographical findings were on the same side and at the same height as the myelographically identified prolapses. Clinical and electromyographical findings did not show significant differences as to the kind of variation, or to the side of the assimilation In sacralisations the prolapses were localised in the 4th lumbar segment, that is, immediately above the variation. In unilateral assimilated vertebrae, disk prolapses were found in two cases in the 4th segment and in 4 cases in the 5th lumbar segment. In three cases prolapse and assimilation were on the same side, in three cases the localisation was median. Patients with lumbalisations had prolapses in seven cases in the 4th, and in four cases in the 5th lumbar segment.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2000

Effect of ultrasound in the treatment of primary nocturnal enuresis.

OBJECTIVE: This study aimed to determine the efficacy of ultrasound therapy in patients with primary nocturnal enuresis. MATERIAL AND METHODS: Thirty-five patients with enuresis were included the study. Patients were divided into two groups: 27 patients with enuresis were treated with ultrasound with irradiation and heating, and eight patients with enuresis were treated with ultrasound without irradiation or heating (placebo group). Ultrasound therapy was performed using the Therasonic 350 machine. The ultrasound therapy was applied to the skin of lumbosacral region. A treatment course of ultrasound comprised 10 sessions of 0.8 W/cm2 intensity applied daily for 8 min. Symptoms were evaluated I week, and 3, 6 and 12 months after the treatment. RESULTS: Twenty-two (81.5%) patients responded to the ultrasound therapy at the first week after the treatment. The effect of ultrasound started immediately after the treatment and continued during the 12 months of the follow-up period. CONCLUSION: Ultrasound therapy seems to be effective in the treatment of primary nocturnal enuresis in the 1 year follow-up period.

Adolescent↗

PubMed1999

Spinal intradural tumours: Part I--Extramedullary.

Sixty-six patients had surgery for an intramedullary nerve sheath tumour under the care of one surgical team in a 16-year period. Surgery concentrated on radical intra- and extradural excision combined if necessary with vertebral column reconstruction. Ninety procedures were used in 35 males and 30 females with an age range 12-81 years. Forty-five per cent were located in the cervical, 26% in the thoracic and 29% in the lumbosacral region. Eighteen patients had NF1 and two patients NF2. Sixty-five per cent were schwannomas, 27% were mixed histology and 6% malignant. In terms of functional outcome, 37 patients improved by one or more Frankel grades, three deteriorated by one Frankel grade and no one who presented with symptoms alone deteriorated. There were no operative deaths; no instrumentation failures and five patients developed a CSF leak.

Adolescent↗

PubMed2000

Spina bifida cystica: selective management in Zaria, Nigeria.

Management of spina bifida cystica in Zaria, Nigeria is selective. Over a period of 11 years, 77 children with this defect, 54 meningocoeles and 23 myelomeningocoeles, 66 (86%) situated in the lumbosacral region, were treated operatively. Forty-two (55%) had surgery in the neonatal period and 91% within 6 months of birth. Postoperative complications occurred in 19 of 68 patients (28%), including mild hydrocephalus, which resolved spontaneously (six, 9%), wound infection (six, 9%), leakage of cerebrospinal fluid (four, 6%) and meningitis (three, 4%). Mortality was 3% from both meningitis and cardiac arrest. Of 32 patients followed up for 3-5 years, 20 with meningocoeles were normal. Of 12 with myelomeningocoele, four had varying degrees of lower limb weakness, three double incontinence, two faecal incontinence, two had progressive hydrocephalus plus paralysis and double incontinence, and one had urinary incontinence. Therefore, 38% were functionally disabled and could not be adequately rehabilitated owing to poor facilities. While management of spina bifida cystica is more aggressive now in most developed countries, ours remains selective due to difficulty with multidisciplinary care and rehabilitation. Even with our selective management, the care of patients with functional handicap remains a challenge.

Developing Countries↗

PubMed2001

Backache in gynaecologists.

The objectives of the study were to assess the overall prevalence of backache in gynaecologists and determine its impact on work, and to identify possible occupational risk factors. The sample comprised gynaecologists, both active and retired, listed as members of the Ulster Obstetrical and Gynaecological Society, who were asked to complete and return a postal questionnaire. The response rate was 94% (107/114). The prevalence of backache, which included pain arising in the thoracic and lumbosacral regions, was 72%. Fifty-three per cent of those with back pain blamed it on working in obstetrics and gynaecology. Overall, 32% of gynaecologists required a change of their work practice, 20% had taken time off work and 8% had required surgery. We conclude that significant morbidity results from backache in gynaecologists. This has economic implications and requires further assessment to improve prevention, with emphasis on individual training and ergonomic evaluation of work-related postures.

Adult↗

PubMed1991

Sensorimotor myeloradiculoneuropathy in thymoma.

This is the first report describing the clinical, electrophysiological, and neuropathological findings in a patient with thymoma and sensorimotor myeloradiculoneuropathy. Degeneration of the Clarke's nucleus and posterior horns were noted in addition to segmental demyelination and variable axonal loss of the anterior and posterior roots. The segmental demyelination was more severe in the anterior roots of the lower thoracic and lumbosacral regions. A possible rare association between paraneoplastic myeloradiculoneuropathy and thymoma is suggested.

Aged↗

PubMed1993

Spinal cord ependymomas treated with surgery and radiation therapy. A review of 11 cases.

Between 1971 and 1990, 11 patients with primary spinal cord ependymomas were treated with surgery and postoperative irradiation or surgery alone at the University of Colorado Health Sciences Center. Of the 11 patients, 6 (54%) were subclassified with myxopapillary ependymomas that were located in the lumbosacral region of the spinal cord: 2 patients underwent complete resections, 8 had subtotal resections, and 1 had a biopsy only; 8 patients received postoperative irradiation (range: 4,500-5,482 cGy) with 7 of 8 patients treated to involved spinal fields. With a mean follow-up of 7.4 years, 3 patients (27%) have developed recurrent disease, 2 in the combined treatment group, and 1 in the surgery alone group. The 5- and 10-year actuarial survival rates were 100% and 80%, respectively. Eight of nine patients (89%) demonstrated clinical improvement after postoperative irradiation which suggests that the irradiation may have contributed to the improvement. The present study supports the long-term survival of patients with spinal cord ependymomas. Results from this series and a review of the literature indicate that complete surgical resection is only possible in about one-quarter of cases. Local spinal irradiation should continue to be utilized when surgery is incomplete.

Adolescent↗

PubMed2002

Intrathecal anesthesia.

PURPOSE OF REVIEW: Development of new drugs and special techniques, as well as changes in health care organization have markedly influenced the use of spinal block and its indications. The present review overviews recent developments in local anesthetic drugs, side effects and special techniques for intrathecal anesthesia. RECENT FINDINGS: Severe complications after spinal anesthesia are acceptably rare. The cardiovascular effects associated with sympathetic block are more frequent but may successfully be treated with volume expansion and administration of vasoactive drugs while the multimodal approach to prevention of such side effects can also reduce the incidence. Based on recent magnetic resonance imaging studies the volume of cerebrospinal fluid at the lumbosacral level is the main determinant of the effects produced by intrathecal injection of local anesthetic solutions. Unfortunately, it is not possible to estimate the volume of cerebrospinal fluid at the lumbosacral region in clinical practice, but it is clear that the total dose of local anesthetic injected into the subarachnoid space is the primary determinant of both therapeutic and unwanted effects of spinal anesthesia. There is overwhelming evidence of the potential risk for neurological dysfunction associated with spinal lidocaine. This evidence is even more relevant in outpatients, in whom lidocaine is primarily indicated. On the other hand, several studies have demonstrated the efficacy and safety of using small doses of long-acting agents, such as bupivacaine or ropivacaine, to produce a short spinal block. The addition of small doses of opioids further helps to minimize the dose of local anesthetic solution required, without affecting the recovery profile from spinal block. The extensive use of pencil-point designs for spinal needles, and the availability of needles of very small size have allowed a significant reduction in the incidence of postdural puncture headache. SUMMARY: The changes in health care organization observed during the past few years have forced us to change the indications for and clinical uses of intrathecal anesthesia techniques in accordance with the changing needs of surgery. The development of new drugs and special techniques for spinal anesthesia will further improve the clinical use of this old but trusted technique.

Journal Article↗

PubMed2000

Current considerations for myelomeningocele repair.

Important advances have been made in the reconstruction of myelomeningocele during the last few years. Techniques of closure that use diverse tissues available in the back range from very simple to very complex. Most of them have become essential to the plastic surgeon. To facilitate a more efficient interdisciplinary approach, recent advances in knowledge of the vascular anatomy of the skin and specific clinical surgical considerations concerning skin grafts, cutaneous flaps, and musculocutaneous flaps are reviewed. A topographical division of the lesion that will permit a methodologically adequate treatment plan for congenital defects in the back, specifically in the thoracic, thoracolumbar, and lumbosacral regions is suggested.

Humans↗

PubMed1993

Ability of Cotrel-Dubousset instrumentation to preserve distal lumbar motion segments in adolescent idiopathic scoliosis.

Between 1985 and 1990, 44 patients with adolescent idiopathic scoliosis were treated with Cotrel-Dubousset instrumentation when Harrington instrumentation would have extended into the distal lumbar spine (L3, L4, or L5) for these curve patterns. Twenty-four of these 44 (group I) patients had one distal fusion level preserved using Cotrel-Dubousset instrumentation, whereas the other 20 patients (group II) were instrumented/fused with Cotrel-Dubousset instrumentation to the expected Harrington instrumentation level in the lower lumbar spine. All patients have a minimum 2-year follow-up, and the average follow-up is 39 months (range 24-74). The characteristics of the group I curves that allowed us to stop the instrumentation a level short included minimal rotation and tilt of the anticipated lowest instrumented vertebra, overall coronal curve flexibility, and nonstructural components to the lumbosacral region of the spine. There were no major differences between these two groups when comparing postoperative coronal and sagittal balance parameters at the most recent follow-up. In select cases, dependent on the preoperative criteria to be discussed, Cotrel-Dubousset instrumentation (vs. traditional Harrington instrumentation) does allow distal lumbar fusion levels to be saved while maintaining acceptable coronal and sagittal balance.

Adolescent↗

PubMedDate not supplied

Pantopaque mimicking spinal lipoma: MR pitfall.

We present a patient with an intraspinal, high-signal-intensity lesion in the lumbosacral region on T1-weighted magnetic resonance images and a thin line of signal void between this region and the CSF on T2-weighted images. These findings were interpreted initially as representing an extradural spinal lipoma. However, CT revealed an intrathecal collection of iophendylate (Pantopaque), which was subsequently removed via a lumbar puncture. The apparent separation of Pantopaque from the CSF (seen on T2-weighted images and interpreted as the dura) was probably caused by chemical shift artifact, chemical shift contour, and/or CSF motion artifact.

Diagnosis, Differential↗

PubMed1992

Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases.

Large administrative databases are increasingly valuable tools for health care research. Although increased access to these databases provides valuable opportunities to study health care utilization, costs and outcomes and valid and comparable results require explicit and consistent analytic methods. Algorithms for identifying surgical and nonsurgical hospitalizations for "mechanical" low back problems in automated databases are described. Sixty-six ICD-9-CM diagnosis and 15 procedure codes that could be applied to patients with mechanical low back problems were identified. Twenty-seven diagnosis and two procedure codes identify hospitalizations for problems definitely in the lumbar or lumbosacral region. Exclusion criteria were developed to eliminate nonmechanical causes of low back pain, such as malignancies, infections, and major trauma. The use of the algorithms is illustrated using national hospital discharge data.

Algorithms↗

PubMed1993

Monitoring of lumbosacral nerve roots during spinal instrumentation.

A technique is described for intraoperative, multimodality electrophysiologic monitoring of the spinal cord and lumbosacral nerve roots (cauda equina). Simultaneous monitoring with the techniques of electromyography, compound muscle action potentials, and somatosensory evoked potentials is found to provide highly useful information to the surgeon during lumbar spine instrumentations. Compound muscle action potential recordings are used to identify nerve roots in the lumbosacral region, especially when visual identification of the nerve is hindered by scarring or distortion of the anatomy. Electromyography continuously monitors nerve roots at risk by revealing neurotonic discharges when the nerve roots are irritated during surgical dissection or placement of the fixation device. The early warning provided by this technique enables the surgeon to avoid irreversible neurologic damage.

Adult↗

PubMed2002

Sacral origin of a spinal dural arteriovenous fistula: case report and review.

STUDY DESIGN: A case of spinal dural arteriovenous fistula arising from a branch of the internal iliac artery is reported. OBJECTIVE: To report a rare case of spinal dural arteriovenous fistula supplied by a lateral sacral artery and treated with endovascular therapy. SUMMARY OF BACKGROUND DATA: Spinal dural arteriovenous fistulas usually occur in the thoracic and lumbosacral regions and arise from the intercostal and lumbar arteries. Rarely, they may occur in the sacral region, as in the reported case. METHODS: A 60-year-old man presented with progressive lower extremity paresis and decreased sensation below the waist of 6 months duration, which had progressed to paraparesis. Diagnostic imaging included magnetic resonance imaging and spinal angiography. RESULTS: A sacral spinal dural arteriovenous fistula was diagnosed with spinal angiography, which showed the spinal dural arteriovenous fistula arising from the right lateral sacral artery branches at S2, and magnetic resonance imaging, which showed enlarged pial vessels along the surface of the spinal cord and central cord hyperintensity, with peripheral hypointensity on T2-weighted images. The patient was definitively treated with endovascular therapy using polyvinyl alcohol particles and Tornado coils. His symptoms almost completely resolved within 6 months of therapy. CONCLUSIONS: Although surgical ligation is the treatment of choice, endovascular therapy may be an effective treatment for patients with sacral region spinal dural arteriovenous fistula in cases of high surgical risk. Spinal angiography remains the definitive diagnostic examination for pinpointing the site of the dural arteriovenous fistula.

Angiography↗

PubMed2002

Correlation of pelvic incidence with low- and high-grade isthmic spondylolisthesis.

PURPOSE: The development of isthmic spondylolisthesis is influenced by forces across the lumbosacral region of the spine. Pelvic incidence is a radiographic parameter that has been shown to be an independent parameter that influences both sagittal spinal balance and pelvic orientation. Our hypothesis then is that there is a positive correlation between pelvic incidence and spondylolisthesis. STUDY DESIGN: A radiographic analysis of cases with spondylolisthesis. OBJECTIVES: To try to assess the correlation between pelvic incidence in both low-grade and high-grade spondylolisthesis in both a pediatric and an adult population. SUMMARY OF BACKGROUND DATA: The concept of pelvic incidence has been introduced into the literature. Its exact association with spondylolisthesis has not yet been clarified. METHODS: Forty patients with spondylolisthesis were identified and divided into two groups: low-grade (Meyerding I-II) and high-grade (Meyerding III and higher). Radiographic parameters measured included lumbar sagittal alignment (T12-S1), sacral inclination, slip angle, and pelvic incidence. The spondylolisthesis was classified according to the Meyerding-Newman classifications and the slip angle. Radiographic measurements were also done in two control groups; there were 20 pediatric and 20 adult controls (mean age 11.8 years and 60.0 years, respectively). Unpaired t test analysis and Pearson correlation analysis were then done. RESULTS: Mean pelvic incidence was 47.4 degrees in the pediatric control group, 57 degrees in the adult control group, 68.5 degrees in the low-grade isthmic spondylolisthesis group, and 79.0 degrees in the high-grade isthmic spondylolisthesis group. Pelvic incidence was found to be significantly higher in the high- and low-grade spondylolisthesis groups compared with both control groups (P = 0.0001). Pelvic incidence was significantly higher in the high-grade isthmic spondylolisthesis group than in the low-grade isthmic spondylolisthesis group (P = 0.007). A significant correlation existed between pelvic incidence and Meyerding-Newman scores (P = 0.03). CONCLUSIONS: Pelvic incidence was significantly higher in patients with low- and high-grade isthmic spondylolisthesis as compared with controls and had significant correlation with the Meyerding-Newman grades (P = 0.03).

Adolescent↗