Nicholas U. Ahn

Septic arthritis of the hip following cortisone injection Case report and review of the literature

Septic arthritis of the hip is a serious medical condition that can result in permanent joint dysfunction. This is a case of a 65-year-old woman who underwent therapeutic intraarticular steroid/lidocaine injection for hip pain and subsequently developed septic arthritis. It is critical that radiologists performing these procedures maintain a high index of suspicion in symptomatic patients following intraarticular injections to prevent destruction of the joint.

Dural ectasia and conventional radiography in the Marfan lumbosacral spine

Abstractu2002Objective. To determine how well conventional radiographic findings can predict the presence of dural ectasia in Marfan patients.nDesign and patients. Twelve Marfan patients without dural ectasia and 21 Marfan patients with dural ectasia were included in the study. Five radiographic measurements were made of the lumbosacral spine: interpediculate distance, scalloping value, sagittal canal diameter, vertebral body width, and transverse process width.nResults. The following measurements were significantly larger in patients with dural ectasia: interpediculate distances at L3–L4 levels (P<0.03); scalloping values at the L1 and L5 levels (P<0.05); sagittal diameters of the vertebral canal at L5–S1 (P<0.03); transverse process to width ratios at L2 (P<0.03). Criteria were developed for diagnosis of dural ectasia in Marfan patients. These included presence of one of the following: interpediculate distance at L4 >38.0 mm, sagittal diameter at S1 >18.0 mm, or scalloping value at L5 >5.5 mm.nConclusion. Dural ectasia in Marfan syndrome is commonly associated with several osseous changes that are observable on conventional radiographs of the lumbosacral spine. Conventional radiography can detect dural ectasia in patients with Marfan syndrome with a very high specificity (91.7%) but a low sensitivity (57.1%).

Plain radiography of the lumbosacral spine in Marfan syndrome

BACKGROUND CONTEXTnMarfan syndrome is a connective tissue disorder that results from a defect in the production of fibrillin. These patients tend to have several osseous anomalies of the lumbosacral spine.nnnPURPOSEnThis study examines the effectiveness of plain radiographic findings in predicting Marfan syndrome.nnnSTUDY DESIGN/SETTINGnCase-control study.nnnPATIENT SAMPLEnFourteen height-matched controls and 33 patients with Marfan syndrome were obtained from our genetics clinic or through the National Marfan Foundation.nnnOUTCOME MEASURESnDetermined using measurements taken on plain radiographs.nnnMETHODSnFive measurements were acquired of the lumbosacral spine from the radiographs of both groups: interpedicular distance, scalloping value, sagittal canal diameter, vertebral body width and transverse process width.nnnRESULTSnThe following measurements were significantly larger in patients with Marfan syndrome: interpedicular distance at L1-L5 (p<.0001); sagittal diameters of the vertebral canal at L4-S2 (p<.01); transverse process to vertebral body width ratio at L2-L5 (p<.01). There was no significant difference in the scalloping values from L1-L5 between the patients with Marfan syndrome and the controls. A multivariate regression analysis generated the following criteria for plain film diagnosis of Marfan syndrome (two criteria need to be met for diagnosis): interpedicular distance at L5 greater than or equal to 36.0 mm, sagittal diameter at L5 greater than or equal to 13.5 mm or transverse process to vertebral width ratio at L3 greater than or equal to 2.25.nnnCONCLUSIONnBased on this criteria, patients can be diagnosed with Marfan syndrome with a high sensitivity (81.8%) but a low specificity (58.3%). Thus, plain radiography can be a useful means of screening patients with Marfan syndrome.

Disproportionately severe calcinosis cutis in an 88-year-old patient with CREST syndrome

Abstract.u2002An 88-year-old woman with CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias) presented with hyperglycemia, intravascular depletion, and atrial fibrillation. The patient was found to have unusually severe calcinosis cutis in both legs extending from the knees to the ankles bilaterally, as well as Raynaud’s phenomenon, sclerodactyly, and telangiectasias. The patient was normocalcemic and normophosphatemic. Although subcutaneous calcification is often seen with CREST syndrome, this case is unusual in that the area of involvement was much larger than previously described. Furthermore, the amount of calcinosis was disproportionately severe and was the major cause of symptoms and disability compared with the other components of the syndrome.

Operative treatment of the patient with neck pain

Most patients with axial neck pain and cervical radiculopathy can be managed conservatively. Surgical intervention for radiculopathy is considered only when conservative management has failed unless the neurologic deficits are very significant. In cases of myelopathy, surgery may be considered earlier, but if the myelopathy is mild, conservative treatment and close observation are still appropriate. For patients with axial neck pain, surgery is generally not considered except for rare cases caused by single- or two-level degenerative disk disease with severe and unrelenting pain. There are many surgical options for the patients with the degenerative cervical spine, but the indications are different. Surgical intervention involves a complete understanding of the disease process both from physical examination and from radiographic studies. If surgery is undertaken without appropriate clinical correlation, poor results often occur. Although the operative planning is the responsibility of the surgeon. the referring physician should also have some awareness of the basic principles behind the different surgeries.

Smoking, smoking cessation, and wound complications after lumbar spine surgery

Abstract Purpose of study: Smoking leads to increased incidence of wound complications after lumbar spine surgery. The paraspinal muscles are perfused by perforating arteries, and smoking may cause diminished vascularity and poor wound healing. This study was performed to determine the extent to which smoking cessation will decrease the risk of developing wound problems after lumbar spine surgery. Methods used: A total of 1,225 patients who had undergone lumbar surgery between 1997 and 2000 were retrospectively studied. Medical records and questionnaires were used to determine information on smoking history and cessation before surgery. Information was also collected on age, sex, BMI, levels exposed, whether fusion was performed and whether the surgery was a revision. The outcome measure was the presence of a wound complication that included wound infection (deep or superficial; n=7), seroma or hematoma formation (n=6), breakdown requiring wound care (n=9) and persistent drainage (greater than 7 days) requiring administration of oral antibiotics (n=21). A stepwise logistic regression analysis was performed to determine the effect of smoking and smoking cessation on wound complications. of findings: Positive smoking history was a risk factor for wound infection (OR=1.47, p=.04). The risk increased for patients who smoked two or more packs a day (OR=2.95, p=.03). Patients who had ceased smoking for at least 3 months were not at significantly higher risk for wound complications than nonsmokers (OR=1.12, p>.05). Relationship between findings and existing knowledge: Previous studies have demonstrated a relationship between wound infection and smoking after lumbar spine surgery. However, the effects of increased smoking and smoking cessation have not been determined. Overall significance of findings: Wound complications after lumbar spine surgery are more common in smokers than in nonsmokers. Patients who smoke two or more packs per day are at nearly three times the risk of developing a wound complication. Smoking cessation 3 months or more before surgery may reduce the risk of wound complication, and patients who are smokers should be encouraged to quit before surgery. Disclosures: No disclosures. Conflict of interest: No conflicts.

The lumbar interpediculate distance is widened in adults with the Marfan syndrome: Data from 32 cases

32 patients with Marfan syndrome, diagnosed with DePaepes criteria, volunteered for this study. All patients underwent standard anteroposterior radiographs of the lumbar spine. Interpediculate distances (IPD) at each level were compared to those of previously established norms. Criteria were developed to determine the presence of Marfan using cut-off values for the IPDs at each lumbar level. The IPDs were significantly larger in the Marfan patients at all lumbar levels. Cut-off values were calculated setting the specificity at 95% at each lumbar level. The cut-off value at L4 yielded the greatest sensitivity. We conclude that the IPDs are widened in patients with Marfan syndrome. The IPD at L4 is a good criterion for Marfan with specificity of 95% and sensitivity of 75%. One must consider using this as a skeletal criterion or a screening tool for Marfan.

Wednesday, October 30, 2001 4:42–5:25 pm Concurrent Session 2B: Lumbar Fusion Complications

Abstract Purpose of study: Posterior decompression and single-level posterolateral fusion is a well-accepted means of treating symptomatic grade 1–2 lumbar spondylolisthesis. Patients often present with lower extremity (LE) radiculopathy in addition to low back pain. This study was performed to determine whether residual LE pain is secondary to continued radiculopathy or to bone graft site harvest. Methods used: A total of 1,225 patients who had undergone lumbar surgery between 1997 and 2000 were retrospectively studied; 137 patients had undergone single-level posterolateral lumbar fusion for grade 1–2 spondylolisthesis that failed conservative treatment and were available for minimum 2-year follow-up. All patients had iliac crest bone graft site harvest contralateral to the side with the more severe radiculopathy preoperatively. Patients with continued LE discomfort were examined postoperatively to determine whether radicular signs were present and whether tenderness was present directly over the bone graft harvest site. of findings: Twenty-three patients (16.8%) continued to have some LE pain postoperatively. In 19 patients (82.6%) this pain was on the bone graft side. Postoperative physical examination demonstrated that in all 19 of these patients, radicular signs were absent, but tenderness localized to the buttock/posterior iliac crest area was present. Only 1 of the 23 patients had true residual radiculopathy. Fishers exact test showed that the proportion of patients with residual LE pain and bone graft site findings was significantly greater than the proportion of patients with residual LE pain and radiculopathy (p Relationship between findings and existing knowledge: Excellent fusion rates and clinical outcomes have been reported for single-level posterior decompression and fusion for grade 1–2 spondylolisthesis. Although resolution of radicular symptoms is more reliable than relief of back pain, some patients still do complain of some LE pain postoperatively. Little is known about whether this is the result of true radiculopathy or the result of bone graft site pain. Overall significance of findings: Radiculopathy after single-level decompression and posterolateral fusion for lumbar grade 1–2 spondylolisthesis is rare. Patients with residual LE pain after this surgery most often have symptoms secondary to iliac crest bone graft harvest. The clinician must be aware of this and perform a thorough examination to prevent unnecessary reoperation for residual LE symptoms. Disclosures: No disclosures. Conflict of interest: No conflicts.

2:32 Effect of nutrient concentration and osteogenic protein–1 on the metabolism of intervertebral disc

Abstract Purpose of study: Poor vascularity to the intervertebral discs (IVD) and sclerosis of the end plate may result in the decrease of nutrient diffusion and subsequent disc deterioration. The purpose of this study was to determine the effect of nutrition on disc metabolism using our recently developed in vitro organ culture model with end plate, and to see if osteogenic protein (OP)-1 can protect discs from a low-nutrient environment. Methods used: Twenty-four lumbar IVDs were obtained from adult New Zealand rabbits weighing 3 kg. Specimens were cultured over 21 days in DMEM/F12 with different concentrations of FBS (5%, 10% and 20%). Four of the specimens cultured in 5% FBS were injected with 0.2 mg OP-1 at 7 days. At 21 days, discs were dissected from end plate and annulus fibrosus (AF) and nucleus pulposus (NP) were separated. After measuring dry weight, the AF and NP tissue were analyzed for DNA content and proteoglycan content (PG) by Hoechst dye method and DMB, respectively. The results were statistically analyzed using analysis of variance with a Fishers PLSD test as a post hoc test. of findings: The DNA content of the NP decreased as the concentration of FBS decreased (5%=1.28 ug/mg, 10%=2.67 ug/mg, 20%=3.92 ug/mg; p=.03). The PG content in NP showed a positive correlation with the concentration of FBS (5%=25.4 ug/mg, 10%=95.5 ug/mg, 20%=152.7 ug/mg; p=.02). The concentration of FBS did not, however, have an effect on the DNA or PG content in the AF. Discs cultured in 5% FBS plus OP-1 demonstrated increased DNA content in NP (1.52 ug/mg, p=.04) and PG content in NP (36.1 ug/mg, p=.05) when compared with discs cultured in 5% FBS without OP-1. The DNA content and PG content in the AF were not affected. Relationship between findings and existing knowledge: Numerous studies have demonstrated that decreased vascularity to the IVD is linked to disc degeneration. This is presumably because of decreased nutrition to the disc cells. However, no studies have been done on the direct relationship between nutrient supply and disc growth in an in vitro organ culture. Moreover, no studies are available on the effect of OP-1 on the IVD in the nutrient-poor environment. Overall significance of findings: In the in vitro organ culture system with end plate, the NP is very sensitive to nutrient supply. AF tissue was not dependent on the nutrition. These results suggest that the diminished vascularity and/or sclerotic end plate changes may contribute to the progress of disc degeneration. Administration of OP-1 appears to protect NP tissue from undergoing degeneration from poor disc nutrition. Disclosures: Device or drug: OP-1. Status: investigational. Conflict of interest: No conflicts.

Cauda equina syndrome in a 32-year-old woman following an L5-S1 central lumbar disc herniation

Abstract A 32-year-old woman with a history of chronic low back pain, hypertension, and urinary retention presented to the emergency department with left hip pain radiating to the posterior thigh, medial leg, and foot. Three days after admission, she developed cauda equina syndrome (CES) with decrease in left leg strength and sensation, as well as urinary and rectal incontinence. She was found to have a midline and left paracentral L5–S1 disc herniation on MRI and was taken to the operating room, where an L5–S1 hemilaminectomy and discectomy was performed. Her function improved almost immediately, and continued to improve after discharge from the hospital. In this report, we present a review of the literature on CES and focus on the relation between timing of surgery after the onset of CES and functional outcome.