Predictors of discogenic pain in magnetic resonance imaging:a retrospective study of provocative discography performed by posterolateral approach

Background@#Provocative discography (PD) is a test that is useful in diagnosing discogenic pain (DP). In this study, to diagnose DP, we used a posterolateral approach of needle placement and followed pressure criteria laid down by the Spine Intervention Society. The aim was to identify the correlation between magnetic resonance imaging (MRI) findings (desiccation, high intensity zone and change in shape and size of the disc) and the results of PD. @*Methods@#Records of 50 patients who underwent PD for DP were analyzed. A total of 109 PDs were performed, with 54 suspect and 55 control discs. Alternate pain generators were ruled out. @*Results@#A total of 35 suspect discs were positive on PD. The mean disc pressure in the suspect disc was 31.9 ± 7.9 psi (range, 15-44). Of the 50 patients who underwent PD, 35 had positive MRI findings. A significant positive correlation was found only between disc desiccation and discography result (r = 0.6, P < 0.001). Logistic regression analysis revealed that only desiccation successfully predicted the result of discography (OR = 26.5, P < 0.001); a high intensity zone and a disc protrusion/extrusion had an OR 2.3 and 1.24, respectively. Disc desiccation of Pfirmann grade 3 or more had a sensitivity and specificity of 0.93 and 0.64 respectively in identifying painful discs; the positive likelihood ratio was 2.58 while the negative likelihood ratio was 0.11. @*Conclusions@#In patients with DP, disc desiccation is the most useful MRI feature that predicts a painful disc on PD.

Predictors of discogenic pain in magnetic resonance imaging:a retrospective study of provocative discography performed by posterolateral approach

Background@#Provocative discography (PD) is a test that is useful in diagnosing discogenic pain (DP). In this study, to diagnose DP, we used a posterolateral approach of needle placement and followed pressure criteria laid down by the Spine Intervention Society. The aim was to identify the correlation between magnetic resonance imaging (MRI) findings (desiccation, high intensity zone and change in shape and size of the disc) and the results of PD. @*Methods@#Records of 50 patients who underwent PD for DP were analyzed. A total of 109 PDs were performed, with 54 suspect and 55 control discs. Alternate pain generators were ruled out. @*Results@#A total of 35 suspect discs were positive on PD. The mean disc pressure in the suspect disc was 31.9 ± 7.9 psi (range, 15-44). Of the 50 patients who underwent PD, 35 had positive MRI findings. A significant positive correlation was found only between disc desiccation and discography result (r = 0.6, P < 0.001). Logistic regression analysis revealed that only desiccation successfully predicted the result of discography (OR = 26.5, P < 0.001); a high intensity zone and a disc protrusion/extrusion had an OR 2.3 and 1.24, respectively. Disc desiccation of Pfirmann grade 3 or more had a sensitivity and specificity of 0.93 and 0.64 respectively in identifying painful discs; the positive likelihood ratio was 2.58 while the negative likelihood ratio was 0.11. @*Conclusions@#In patients with DP, disc desiccation is the most useful MRI feature that predicts a painful disc on PD.

Malunion in displaced intracapsular fracture of femoral neck: A rare case / 中华创伤杂志(英文版)

Intracapsular fracture of femoral neck is treated by anatomical reduction (preferably closed) and cannulated cancellous lag screw fixation. Malunion of these fractures have been described in the coronal plane (coxa valga or coxa vara). We reported a case of young adult patient with displaced intracapsular fracture of femoral neck that had malunited in sagittal plane with callus formation with excellent functional outcome. The radiographs revealed intracapsular fracture of femoral neck right side (Garden type 4 and Pauwel type 3). The patient was operated and closed reduction and internal fixation with three cannulated cancellous screws was performed. The postoperative radiograph revealed a loss of reduction in the lateral view. Due to this technical error, the patient was counselled for revision fixation for which he refused. At 9 months we observed union of the fracture in the displaced position by callus formation. Harris hip score at 2 years was 96 that indicate excellent functional outcome and the radiographs did not reveal any evidence of avascular necrosis of femoral head. We advised revision surgery to our patient as he had increased chances of implant failure and nonunion. However he refused the revision surgery and was continued with the suboptimal reduction. However, the fracture united and that too with callus formation, which is not a described phenomenon in neck of femur fracture.

Multiple bilateral lower limb fractures in a 2-year-old child: previously unreported injury with a unique mechanism / 中华创伤杂志(英文版)

Fall from height is a common cause of unintentional injuries in children and accounts for 6% of all trauma-related childhood deaths, usually from head injury. We report a case of a 2-year-old child with multiple fractures of the bilateral lower limbs due to this reason. A child fell from a height of around 15 feet after toppling from a balcony. He developed multiple fractures involving the right femoral shaft, right distal femoral epiphysis (Salter Harris type 2), right distal metaphysis of the tibia and fibula, and undisplaced Salter Harris type 2 epiphyseal injury of the left distal tibia. There were no head, abdominal or spinal injuries. The patient was taken into emergency operation theatre after initial management which consisted of intravenous fluids, blood transfusion, and splintage of both lower limbs. Fracture of the femoral shaft was treated by closed reduction and fixation using two titanium elastic nails. Distal femoral physeal injury required open reduction and fixation with K wires. Distal tibia fractures were closely reduced and managed nonoperatively in both the lower limbs. All the fractures united in four weeks. At the last follow-up, the child had no disability and was able to perform daily activities comfortably. We also proposed the unique mechanism of injury in this report.

Bertolotti Syndrome: A Diagnostic and Management Dilemma for Pain Physicians

BACKGROUND: Bertolotti's syndrome (BS), a form of lumbago in lumbosacral transitional vertebrae, is an important cause of low back pain in young patients. The purpose of this study was to assess the etiology of low back pain and the efficacy of treatment offered to patients with BS. METHODS: All patients of BS Castellvi type1a during a period of 6 months were enrolled in the study. The patients underwent interventional pain procedures for diagnosis and pain relief. Response to the therapy was assessed based on VAS and ODI scores. A 50% decrease in VAS score or a VAS score less than 3 would be considered adequate pain relief. RESULTS: All 20 patients diagnosed with BS during the 6-month observation period had scoliosis. Common causes of back pain were the ipsilateral L5-S1 facet joint, neoarticulation, the SI joint, and disc degeneration. Responses to various interventions for pain relief were different and inconsistent from patient to patient. In particular, responses to interventions for neoarticular pain were generally poor. CONCLUSIONS: Pain in patients with BS does not usually respond to interventional pain treatment. A very dynamic treatment approach must be pursued while managing BS patients, and the treatment plan must be individualized at various stages in order to obtain satisfactory pain relief.

Hoffa fracture associated with femoral shaft and proximal tibial fractures: report of two cases / 中华创伤杂志(英文版)

Solitary coronal shear fractures of femoral condyle, such as Hoffa's fracture, are usually associated with supracondylar or intercondylar fractures of the femur. These fractures are rare and seen in the context of high energy mechanism leading to multiple injuries; therefore a thorough workup of the patient is required to rule out other significant injuries. Hoffa's fracture associated with femoral shaft and proximal tibial fractures is extremely rare and no such injury has been reported previously. We report two such cases which were managed with standard operative fixation techniques and demonstrated good to excellent functional outcome after a follow-up of one year. This report emphasizes that high index of suspicion is required for di- agnosis of these injuries and a thorough workup is mandatory to rule out other associated injuries. We also propose a possible mechanism of injury.