Qaiser Shafiq

Effect of the increase in the height of lumbar disc space on facet joint articulation area in sagittal plane.

Study Design. Computerized tomography (CT) of the lumbar spine cadaveric specimens was used to evaluate the effect of increasing the height of the disc space in the lumbar spine to the facet joint articulation in the sagittal plane. Objective. To show how the facet joint articulation is affected by increasing the height of the disc space in the lumbar spine. Summary of Background Data. The Charité Artificial Disc (DePuy Spine, Inc., Raynham, MA) was successful in relieving low back pain in the majority of patients, yet there was still a significant number of patients who did not obtain pain relief, or their pain even worsened. The etiology of their pain is still not known. To our knowledge, no study has addressed the effect on the facet joints when the disc height is increased. Methods. CT images passing through the center of the L3–S1 facet joints (sagittal plane) were obtained from 15 cadaveric lumbar spine specimens. The articulation overlap of facet joints in sagittal plane from the L3 to S1 was measured. A 1-mm incremental increase to a total 5 mm in disc space height was performed to simulate the changes seen in disc replacement. The change in the facet joint articulation overlap in sagittal plane at normal and each displacement was then measured. There were 5 lumbar spine specimens dissected to validate the technique and standardize the measurements. Mean, percentages, and standard deviation values were calculated for all measured dimensions. Results. No significant difference was found between the measurements on CT and gross specimens (P > 0.05). In 15 specimens, the mean facet joint articulation overlap on the sagittal plane was: 16.29 ± 1.20 mm (left) and 16.22 ± 1.16 (right) at the L3–L4 level; 17.81 ± 1.18 mm (left) and 17.74 ± 1.18 mm (right) at the L4–L5 level; and 18.18 ± 1.18 mm (left) and 18.23 ± 1.15 mm (right) at the L5–S1 level. There is no significant difference between the measured values on left and right sides (P > 0.05). Each 1-mm incremental increase in disc space at the L3–L4 level translated to a decrease in the facet joint articulation overlap in the sagittal plane by 6%, and the mean facet joint space increased 0.4 mm. At the L4–L5 level, the articulation overlap decreased by 6%, and the facet joint space increased 0.5 mm. At the L5–S1 level, the articulation overlap decreased by 4%, and the facet joint space increased 0.7 mm. Conclusions. There is a significant decrease of the facet joint articulation overlap in sagittal plane and an increase in the facet joint space following an increase in the lumbar disc space. The inappropriate increase of the height of disc space will result in facet joint subluxation.

Quantitative analysis of changes in cervical intervertebral foramen size with vertebral translation.

Study Design. Simulated translation of the C5 vertebra was performed in 20 embalmed cadaveric cervical spines, and cross-sectional areas of the C4–C5 and C5–C6 intervertebral foramina were measured and compared before and after translation of the C5 vertebra. Objective. To determine the relationship of cross-sectional intervertebral foraminal areas to the degrees of vertebral translation. Summary of Background Data. The common feature of clinical instability and adjacent diseases of the cervical spine is malalignment of the cervical spine (i.e., there is ventral and dorsal translation of vertebral body with respect to the adjacent upper and lower vertebral body, respectively). To our knowledge, no previous study has analyzed the quantitative effect of vertebral translation on the size of the intervertebral foramina. Methods. The cross-sectional areas of the intervertebral foramina at C4–C5 and C5–C6 were measured on computerized tomography. The images were then transferred to the personal computer, where consecutive dorsal translations of C5 vertebrae with a 1-mm increment from 1 to 5-mm displacements were performed using Microsoft paint software (Microsoft, Corp., Redmond, WA). National Institutes of Health (Bethesda, MD) Image J software (V1.33m) was then used to measure the areas of both sides of C4–C5 and C4–C6 foramina at normal and each displacement level in the computer. Results. Following dorsal translation of C5 vertebra, anterolisthesis of C4 relative to C5 and retrolisthesis of C5 relative to C6 was noted. No significant difference was found between the measured values using Aquarius Image software (Microsoft, Corp.) on computerized tomography and National Institutes of Health image J software on the desktop computer (P > 0.05). When compared with normal values, there was an increase in the C4–C5 intervertebral foraminal area (i.e., 6%, 14%, 18%, 21%, and 26% with anterolisthesis of C4 relative to C5 following 1, 2, 3, 4, and 5-mm dorsal translation of the C5 vertebra, respectively). There was a 12% decrease in the C5–C6 intervertebral foraminal area, with each 1-mm incremental retrolisthesis of C5 relative to C6 vertebra. Statistically significant differences were found among residual cross-sectional foraminal areas following different degrees of dorsal translation (P < 0.05). Conclusion. There is a significant increase in size with anterolisthesis and decrease in size with retrolisthesis of upper and lower adjacent vertebral intervertebral foramina, respectively.

Practical echocardiographic approach for risk stratification of patients with acute pulmonary embolism

Acute pulmonary embolism remains a common cause of mortality. Early diagnosis and appropriate risk stratification is necessary to individualize treatment strategy. Computed tomography scan of the pulmonary arteries is routinely used to diagnose acute pulmonary embolism and in some cases is useful to assess right ventricular dilation. In patients with acute pulmonary embolism, right ventricular dilation and dysfunction indicates a high-risk situation where immediate administration of thrombolytic agent, catheter-directed thrombolysis, or surgical embolectomy could be considered. A bedside 2D echocardiogram at the time of presentation could provide additional morphological, functional, and hemodynamic parameters including right ventricular dilation, McConnell’s sign, reduced tricuspid annular plane systolic excursion (TAPSE), interventricular septal flattening, abnormal right ventricular hemodynamics and in rare cases thrombi in the inferior vena cava, right atrium or ventricle en route to pulmonary arteries may also be visualized. This additional information is useful for selection of appropriate treatment modality. Thus, our objective is to provide a practical echocardiographic approach for risk stratification of patients with acute pulmonary embolism.

Enlarged perforating branch of peroneal artery and extra crural fascia in close relationship with the tibiofibular syndesmosis

We found an extremely large perforating branch of peroneal artery in an 89-year-old female cadaver’s left ankle. The anterior tibial artery could not reach to supply the ankle and dorsum of the foot. The perforating branch of peroneal artery continued as the dorsalis pedis after giving off an anterior lateral malleolar artery branch. The posterior tibial artery was thinner than usual. On the anterior side of the ankle, there was an extra crural fascia in addition to the regular crural fascia, under the anterior crural muscles. This strong fascia was tightly overlying the perforating branch of peroneal artery and anterior tibiofibular ligament. It is important to know the relationship of these vessels to the surrounding structures. Surgeons must be careful while dissecting this area since the perforating branch of peroneal artery might be anomalously enlarged as well as crossing in front of the tibiofibular syndesmosis in order to prevent vascular injury.

ST-Segment Elevations Secondary to Electrical Cardioversion

A 56-year-old woman with primary pulmonary hypertension presented with increasing shortness of breath and palpitations. ECG showed right bundle-branch block and slow atrial flutter with 2:1 AV block (Figure 1). In view of the patient’s hypotension …

Embolic Stroke Due to Sinus of Valsalva Aneurysm Thrombus

Embolic Stroke Due to Sinus of Valsalva Aneurysm Thrombus Sinus of valsalva aneurysms are rare and a prevalence of 0.09% in the general population is reported by an autopsy study. Thrombus formation in the sinus of valsalva aneurysms are a rare complication and could lead to embolic phenomena. Herein, we report a rare case of sinus of valsalva aneurysm with a thrombus inside it that lead to embolic stroke. An 83-year-old man presented with left arm weakness. Cardiovascular examination was unremarkable except for an irregular pulse and electrocardiogram confirmed atrial fibrillation. Brain magnetic resonance imaging showed an acute infarct in the right frontal lobe. Transesophageal echocardiogram demonstrated no intracardiac thrombi. However, sinuses of valsalva aneurysm with a large thrombus was observed (Figure A). Computed tomography scan of the chest showed aneurysmal dilatation of 2 sinuses of the valsalva; the first, involving the left coronary sinus, was 6.2 4.7 cm in size and contained a large thrombus, the second aneurysm was 2.1 1.7 cm in size and involved the right coronary sinus (Figure B). Thrombus within the sinus of valsalva aneurysm was considered the source of embolic stroke. Considering the large size of the aneurysms, the risk of rupture and the potential for future thromboembolic events, cardiothoracic consultation was obtained. The patient underwent resection of the sinus of valsalva aneurysms and aortic root repair with Medtronic

Dual Anomalous Origins of the Thyrocervical Trunk and Left Internal Mammary Artery.

A 56-year-old man with diabetes and a history of triple coronary artery bypass graft surgery (left internal mammary artery [LIMA] to left anterior descending [LAD] artery, saphenous vein grafts to posterior descending artery and obtuse marginal artery) underwent coronary catheterization for

A Seedless Grape in the Heart

A 65-year-old woman was admitted with shortness of breath and chest pain. A computed tomographic angiogram of the chest performed for suspected pulmonary embolism showed a filling defect in the left atrium, concerning for a tumor or thrombus (Figure, A). Transesophageal echocardiography revealed a large mobile mass in the left atrium attached to the interatrial septum with a very short pedicle (Figure, B and Movie I in the online-only Data Supplement). The patient had a history of surgical patent foramen ovale closure with a Prolene suture, mitral valve repair, and saphenous vein bypass graft to the right coronary …