Purpose: Vascular complications in lumbar disc surgery are rare, difficult to diagnose and may have serious consequences. We review our experience in eight cases treated in the past 30 years. Methods: Between 1976 and 2005 we operated on 16,391 cases of vascular pathology, eight for vascular complications after lumbar discectomy (herniated disc), six men and two women aged 36 to 70 (mean 52 years). The symptoms were abdominal pain in four, ischial irradiation in one, episodes of heart failure in one, limb oedema in two, acute haemorrhage in three, abdominal murmur in two. The diagnosis was made during surgery in two cases and immediately postoperative in the third due to severe hypovolemia. The others were diagnosed because of abdominal murmur, limb oedema and suspected abdominal aneurism. Abdominal CT scans and arteriography were performed in five cases. Treatment was surgical, with direct closure in seven cases and interposition of a Dacron aortoiliac prosthesis in the other. No sequelae were seen during follow-up, which lasted a maximum of fifteen years. All the patients returned to normal life and there was no mortality. Conclusions: Because of the severity and rareness of this complication, few cases have been described in the literature, and its real incidence is therefore unknown. We should think of it whenever there is any unexplained, sustained haemodynamic disorder during lumbar disc surgery or immediately postoperative. Treatment should be immediate

A 51-year-old Caucasian woman was admitted to the Rheumatology Department of our hospital due to a 3-week history of diffuse neck, shoulder and upper torso pain, exacerbated by movements. An outpatient trial of non-steroidal anti-inflammatory medications had been unsuccessful. A few days later, the pain was localised above the manubrium, the left clavicle and sternomastoid muscle and fever up to 39.5°C was reported. The patient had no significant past medical history and lived in a suburban area. She did not work and liked to do gardening in her spare time. There was no history of local trauma or any medications. On examination, there was intense redness, tenderness and swelling of the manubrium and the left sternoclavicular joint. Chest CT revealed osteolytic changes of the manubrium and presence of inflammatory tissue surrounding the manubrium and extending posteriorly. The lung parenchyma was unaffected. Brain and abdominal CT were unremarkable. A triple-phase bone scan was indicative of sternal osteomyelitis without other bone involvement. Blood and urine cultures remained negative. The patient was empirically treated with high-dose intravenous vancomycin and ciprofloxacin with no response. Antibody testing to human immunodeficiency virus and hepatitis viruses was negative. An open biopsy was performed 1 week later, revealing persistent inflammatory tissue around the sternum and fluid collection posteriorly. Multiple bone specimens were sent for histological examination and cultures. Histology showed acute and chronic granulomatous inflammation, while both cultures of the bone marrow and the fluid revealed Nocardia nova. No other pathogen was identified. The patient responded to high-dose intravenous trimethoprim-sulfamethoxazole, which was continued on an outpatient basis for 1 year without further sequelae. This is the first reported case of primary sternal osteomyelitis due to Nocardia species. The possibility of nocardiosis needs to be included in the differential diagnosis of sternal osteomyelitis, even for apparently immunocompetent adults

Introduction Central placement of a total disc arthroplasty (TDA) in the coronal plane will result in equivalent facet joint loading, less tendency for lateral core migration, optimum kinematics, and better outcomes. This study was performed to determine which of the radiographic markers – the vertebral body, the pedicles, or the spinous process – provides the most accurate guide to the coronal midline, so to optimise coronal TDA. The coronal midline was defined as the perpendicular bisector of a line drawn between the midpoints of the two facet joints. Methods Axial CT images were reconstructed from 35 abdominal CT’s to show the relevant anatomy at L4, L5, and S1. Measurements were taken comparing the consistency of the midpoints of the vertebral body, the pedicles, and the spinous processes, in relation to the coronal midline. Results The mean distance from the coronal midline to the vertebral body midpoint was 0.55mm (SD 0.45), to the interpedicular midpoint was 0.19mm (SD 0.40), and to the spinous process midpoint was and 1.30mm (SD 1.30). 16% of the distances from the coronal midline to the spinous process midpoint were greater than or equal to 3mm, compared with 0% of the distances to the interpedicular midpoint or the vertebral body midpoint. The interpedicular midpoint was significantly closer to the coronal midline than the spinous process midpoint or the vertebral body midpoint at all levels (p< 0.001). Discussion The interpedicular midpoint is the most accurate guide to the coronal midline. We recommend this landmark be used in preference to the spinous processes or the vertebral body midpoint when placing the implant in TDA. The close location of the interpedicular midpoint to the implant, compared with the more posteriorly located spinous process, means the likelihood of parallax error, by rotation of the patient or the C arm, is reduced using the interpedicular midpoint

Summary Statement. It is now possible to diagnose osteoporosis using incidental abdominal CT scans; applying this approach to fractures of the cervical spine demonstrates levels of osteoporosis in patients over 65. Introduction. Recently published data now makes it possible to screen for osteoporosis in patients who, in the course of their hospital stay, have had Computed Tomography (CT) scans of their abdomen for reasons other than direct imaging. This is as a result of CT derived bone mineral density (BMD) in the first lumbar vertebra (L1) being correlated BMD derived from Dual-energy X-ray absorptiometry (DEXA) scans. The advantage of this is the reduction in both cost and radiation exposure. Although age has a detrimental effect on BMD, relatively few patients have formal DEXA studies. The aims of this study were to evaluate the utility of this new technique in a cohort of patients with acute fractures of the cervical spine and to compare relative values for BMD in patients aged over 65 with those aged under 65, and thus define the role of osteoporosis in these injuries. Methods & Patients. Following Institutional review board approval, we performed a retrospective study of patients who presented to a level I trauma center with acute fractures of the cervical spine between 2010 and 2013; patients also had to have had a CT scan of their L1 vertebra either during the admission or within 6 months of their admission (for any other clinical reason). Using a picture archiving and communication (PACS) system, we generated regions of interest (ROI) of similar size in the body of L1 (excluding the cortex), in line with the publication by Pickhardt et al., and computed the mean values for Hounsfield units (HU). These values were compared against established threshold values which differentiate between osteoporosis and osteopenia; for a balanced sensitivity and specificity, <135 HU is the threshold and for 90% sensitivity a HU threshold of <160 HU is set. Comparisons were also performed between age stratified groups. Results. A total of 187 patients were reviewed for eligibility, 91 patients met the criteria with 53 patients aged 64 years or younger (range 23–64) and 38 patients aged above 65 years (range 65–98). In the younger cohort, 6/53 (11% were osteoporotic, using the lower threshold, while the higher threshold indicated 5/53 (17%) of patients under 65 years were osteoporotic; mean HU for the group was 195.8 (SD 43.3). In the older cohort, 24/38 (63%) were osteoporotic using the lower threshold, whereas 34/38 (89%) were osteoporotic using the higher threshold. Mean HU for the cohort aged over 65 years was 118.7 (SD 38.4). Age based comparison of the mean values, regardless of threshold, was statistically significant (p<0.001) in both cases. Discussion and Conclusions. This study demonstrates, for the first time in the cervical spine (including C2), the role of age related osteoporosis in acute fractures of the cervical spine. This new technique harnessing the presence of opportunistic CT scans of the abdomen saves on the extra cost and radiation exposure that may be associated with DEXA scanning. In younger patients, the higher threshold indicated 17% were osteoporotic – in the setting of an opportunistic scan, this may afford them the opportunity to commence prophylactic treatment to prevent future fractures. We believe these result have the potential to significantly impact future clinical practice

Summary Statement. Using abdominal CT scans to evaluate bone mineral density following acute fractures of the thoracic and lumbar spine demonstrates significant levels of osteoporosis in older patients; this approach may help save on time and resources, and reduce unnecessary radiation exposure. Introduction. While a reduction in bone mineral density (BMD) is associated with aging, relatively few patients have formal dual-energy X-ray absorptiometry (DXA) to quantify the magnitude of bone loss, as they age. This loss of bone may predispose to fractures. Recent data, which correlates mean Hounsfield units (HU) in an area of the L1 vertebra with BMD, now makes it possible to screen for osteoporosis using incidental abdominal Computed Tomography (CT) scans to measure bone density. This innovation has the potential to reduce both cost and radiation exposure, and also make it easier to identify patients who may be at risk. The aims of this study were to evaluate the utility of this approach in patients with acute thoracic and lumbar spine fractures and to evaluate the impact of aging on BMD, using CT screening. Patients & Methods. Following institutional review board approval, we performed a retrospective study of patients who presented to a level I trauma center with acute fractures of the thoracic and lumbar spine between 2010 and 2013; patients also had to have had an abdominal (or L1) CT scan either during the admission or in the 6 months before or after their injury. Using a picture archiving and communication (PACS) system, we generated regions of interest (ROI) of similar size in the body of L1 (excluding the cortex) and computed mean values for HU. Values derived were compared against threshold values which differentiate between osteoporosis and osteopenia - for specificity of 90%, a threshold of 110 was set; for balanced sensitivity and specificity, a threshold of <135 HU was set and for 90% sensitivity a threshold of <160 HU was set. A student's t test was used to compare the age stratified mean HU (younger than 65yrs; 65yrs and older), while Fisher's exact test was used to perform aged stratified comparisons between the proportions of patients above and below the thresholds outlined (in each of the three threshold groups). Results. A total of 124 patients were evaluated, with 74 having thoracic and 50 having lumbar fractures. Among those with thoracic fractures, there were 33patients in the younger cohort, who also had a mean BMD of 196.51HU and 41 in the older cohort, who had mean BMD of 105.90HU (p<0.001). In patients with lumbar fractures, 27 patients were in the younger cohort, with mean BMD of 192.26HU and 23 patients in the older cohort with mean BMD of 114.31HU (p<0.001). At the threshold of 110 HU, set for specificity, the magnitude of difference between the age stratified cohorts was greater in the thoracic spine (p<0.001 vs. p=0.003). At the other thresholds: 135HU (balanced for sensitivity and specificity) and 160 HU (90% sensitivity), age of 65 years or older was significantly associated with reduction in CT derived measure of BMD (p<0.001 in all cases). Discussion. This study demonstrates the relative frequency of osteoporosis in acute fractures of the thoracic and lumbar spine, and how this changes with age; it is also the first study to do this using opportunistic CT scans. There seems to be a strong association between a reduction in bone mineral density and advanced age, in patients presenting with acute fractures of the spine. This approach may save on the extra cost and additional radiation exposure that may be associated with DXA scanning; in addition, it may help provide clinicians and patients with an approach to monitor developing problems with BMD before it becomes clinically apparent, especially in younger patients

Introduction: Chance fractures in children are rare the mechanism of injury is a flexion-distraction inertial force created during a motor vehicle accident when wearing a two-point seat belt or lap belt. High velocity paediatric Chance fractures are frequently associated with intra-abdominal injuries, although this may not be appreciated at the time of initial presentation. Methods: The cases of two brothers who sustained Chance fractures with complete neurological deficits and intra-abdominal injuries from a motor vehicle accident are presented. Results: The two brothers were rear seat passengers in car involved in a head-on collision with a tree. They were both wearing three point seat belts but had removed the chest straps, thus effectively converting them to a two-point harness. Case 1. Boy age 3 years 10 months sustained a bony Chance fracture through the L3 vertebrae with a complete neurological deficit at the L1 level. There was an associated closed head injury and severe abdominal bruising. He underwent a CT scan of his abdomen on day of admission and posterior stabilisation of the spinal fracture on day 4. Seven days post-admission he was diagnosed with pancreatitis. He continued to have abdominal pain and vomiting. Further repeat abdominal CT scans, ultrasound examinations and abdominal contrast studies were performed. Ten weeks following admission he underwent laparotomy and a section of ischaemic small bowel was removed. Case 2. Boy age 2 years 8 months presented with a ligamentous Chance fracture of L2 / L3 with a complete neurological deficit at T12. He had a closed head injury and severe abdominal bruising. He underwent CT scan on the day of admission and a diagnostic peritoneal tap on day two with aspiration of straw coloured fluid. The spinal fracture was stabilised 10 days post-admission with posterior instrumentation. On day 14 he underwent a laparoscopy and subsequent laparotomy with drainage of an abscess secondary to a perforated caecum. Discussion: Chance fractures or flexion-distraction fractures of the spine are rare occurrences in children with few cases reported. They represent severe trauma and are often related to the wearing of two-point seat belt fixation. There is a high associated incidence of abdominal injuries which may be difficult to diagnose. The authors support the view of Beaunoyer. 1. that a diagnostic laparoscopy or laparotomy should be considered strongly in patients with lumbar Chance fractures. Abdominal bruising and neurological defi cit are cardinal signs, reflecting severe trauma

Aims

This study aimed to develop and validate a fully automated system that quantifies proximal femoral bone mineral density (BMD) from CT images.

Auckland City Hospital, Auckland, New Zealand. To show that the spinous processes (SPs) increase in size with age. To investigate the incidence of SP abutment, relationship to disc degeneration and age related kyphosis. Describe patterns of SP neoarticulation in relation to back pain and intersegmental axial rotation and deformity. We reviewed 200 Abdominal CTs, CT myelograms and 100 standing x-rays (age 18-90 years). We measured SP size, interspinous gap, patterns of neoarticulation, disc height, lumbar lordosis and axial rotation. We compared symptomatic and asymptomatic groups. A 30-50% increase in SP size coupled combined with a loss of disc height leads to increasing rates of SP abutment after the age of 35 years. 30% of people over the age of 60 years have SP abutment. There is a 15 degree increase in standing lumbar kyphosis with age. Four patterns of SP neoarticulation are seen. Degenerative changes in the SP articulation increase by more than 80% in a symptomatic cohort. Oblique SP articulation is 2.5 times more likely in symptomatic individuals and associated with a rotational intersegmental deformity. Ageing is accompanied by SP enlargement and abutment, contributing to a loss of lumbar lordosis. Patterns of neoarticulation and degeneration appear associated with back pain and rotational deformity

Objectives

The clinical utility of routine cross sectional imaging of the abdomen and pelvis in the screening and surveillance of patients with primary soft-tissue sarcoma of the extremities for metastatic disease is controversial, based on its questionable yield paired with concerns regarding the risks of radiation exposure, cost, and morbidity resulting from false positive findings.

The August 2012 Spine Roundup³⁶⁰ looks at: neural tissue and polymerising bone cement; a new prognostic score for spinal metastases from prostatic tumours; recovery after spinal decompression; spinal tuberculosis; unintended durotomy at spinal surgery; how carrying a load on your head can damage the cervical spine; and how age changes your lumbar spine.