Ligamentum Flavum Rupture by Epidural Injection Using Ultrasound with SMI Method.

The loss of resistance (LOR) method has been used exclusively to identify epidural space. It is difficult to find the epidural space without the risk of dural puncture. Various devices have been developed to improve the accuracy of the LOR method; however, no method has overcome the problems completely. Therefore, we devised a ligamentum flavum rupture method (LFRM) in which the needle tip is placed only on the ligamentum flavum during the epidural injection, and the injection pressure is used to rupture the ligamentum flavum and spread the drug into the epidural space. We confirmed the accuracy of this method using ultrasound with superb microvascular imaging (SMI) to visualize the epidural space. Here, we report two cases of 63-year-old and 90-year-old males. The 63-year-old patient presented with severe pain in his right buttock that extended to the posterior lower leg. The 90-year-old patient presented with intermittent claudication every 10 min. LFRM was performed, and SMI was used to confirm that the parenteral solution had spread into the epidural space. Our results indicate that LFRM can be used for interlaminar lumbar epidural steroid injections.

Minimally invasive 360-degree pelvic ring fixation using a combination of crab-shaped fixation and pelvic internal fixator for unstable pelvic ring fracture: A case report.

Surgery with both anterior and posterior fixation is recommended for unstable pelvic ring fractures; nonetheless, the surgical method remains controversial. Crab-shaped fixation is a minimally invasive and strong posterior fixation method using spinal instruments that can reduce vertical dislocations. The use of pelvic internal fixator as a minimally invasive anterior fixation method has been reported. It is recommended in cases where there is an open wound in the lower abdomen or damage to the pelvic organs. Conversely, to the best of our knowledge, there has been no report on the combined use of crab-shaped fixation and pelvic internal fixator to date. We performed a minimally invasive 360-degree fixation using a combination of crab-shaped fixation and pelvic internal fixator for an unstable pelvic ring fracture (AO-C2) and sacral fracture (Denis zone II) with 15-mm vertical dislocation. The sacral fracture was accompanied by a large bone fragment in the spinal canal, which was suspected to have caused neuropathy. Therefore, in addition to posterior fixation, we performed decompression and removed the bone fragment. Postoperative computed tomography revealed that the sacral vertical dislocation was reduced to 7.5 mm. The patient started getting out of bed on postoperative day 2. His neuropathy improved after surgery. Owing to abdominal discomfort, pelvic internal fixator was extracted at 3 months postoperatively. Bone fusion was completed, and posterior fixation was removed at 9 months postoperatively. Two years after, the patient walks independently and has returned to work. Minimally invasive 360-degree pelvic ring fixation is a treatment option for an unstable pelvic ring fracture (AO-C2).