Caffey's Disease of the Scapula: A Case Report.

Infantile cortical hyperostosis also named as Caffey's disease is a rare self-limiting inflammatory disease that usually affects children during infancy. It is characterized by subperiosteal new bone formation usually involving the diaphysis of long bone as well as the ribs, mandible, scapula, and ribs. It is crucial to diagnose the disease at an earlier stage to avoid superfluous surgery. We report a rare case of infantile cortical hyperostosis of the scapula, its clinical and radiological features.

ISSLS PRIZE in basic science 2023: Lactate in lumbar discs-metabolic waste or energy biofuel? Insights from in vivo MRS and T2r analysis following exercise and nimodipine in healthy volunteers.

PURPOSE: To quantitatively assess the dynamic changes of Lactate in lumbar discs under different physiological conditions using MRS and T2r. METHODS: In step1, MRS and T2r sequences were standardized in 10 volunteers. Step2, analysed effects of high cellular demand. 66 discs of 20 volunteers with no back pain were evaluated pre-exercise (EX-0), immediately after targeted short-time low back exercises (EX-1) and 60 min after (EX-2). In Step 3, to study effects of high glucose and oxygen concentration, 50 lumbar discs in 10 volunteers were analysed before (D0) and after 10 days intake of the calcium channel blocker, nimodipine (D1). RESULTS: Lactate showed a distinctly different response to exercise in that Grade 1 discs with a significant decrease in EX-1 and a trend for normalization in Ex-2. In contrast, Pfirrmann grade 2 and 3 and discs above 40 years showed a higher lactate relative to proteoglycan in EX-0, an increase in lactate EX-1 and mild dip in Ex-2. Similarly, following nimodipine, grade 1 discs showed an increase in lactate which was absent in grade 2 and 3 discs. In contrast, exercise and Nimodipine had no significant change in T2r values and MRS spectrum of proteoglycan, N-acetyl aspartate, carbohydrate, choline, creatine, and glutathione across age groups and Pfirrmann grades. CONCLUSION: MRS documented changes in lactate response to cellular demand which suggested a 'Lactate Symbiotic metabolic Pathway'. The differences in lactate response preceded changes in Proteoglycan/hydration and thus could be a dynamic radiological biomarker of early degeneration.

Spinal Melorheostosis Associated with Intradural Fibrous Band and Extensive Lipomatosis Causing Thoracic Cord Tethering and Myelomalacia: A Unique Case Highlighting Importance of MRI in Management.

Axial melorheostosis is rare with only few cases reported and even fewer with symptoms. While symptoms secondary to neural foramen or spinal canal stenosis caused by hyperostotic bone are common, only three symptomatic cases of spinal melorheostosis with associated intradural lipomatous lesions have been reported to date. In none of them the fibrous component of lipofibromatous lesion was identified preoperatively on magnetic resonance imaging. We report here a case of 18-year-old male who presented with thoracic myelopathy secondary to widespread spinal melorheostosis associated with extensive intradural lipomatosis and fibrous component in thoracic lipoma, causing tethering of thoracic spinal cord and myelomalacia. The patient was treated with T2 to T9 posterior instrumented stabilization followed by T3 to T8 laminectomy along with selective thoracic lipofibromatous tumor debulking. Detection of the fibromatous component in multilevel extensive intradural lipomatosis associated with melorheostosis is helpful in planning selection of the level of surgical excision and decompression.

Are Modic changes 'Primary infective endplatitis'?-insights from multimodal imaging of non-specific low back pain patients and development of a radiological 'Endplate infection probability score'.

PURPOSE: To probe the pathophysiological basis of Modic change (MC) by multimodal imaging rather than by MRI alone. METHODS: Nineteen radiological signs found in mild infections and traumatic endplate fractures were identified by MRI and CT, and by elimination, three signs unique to infection and trauma were distilled. By ranking the Z score, radiological 'Endplate Infection Probability Score' (EIPS) was developed. The score's ability to differentiate infection and traumatic endplate changes (EPC) was validated in a fresh set of 15 patients each, with documented infection and trauma. The EIPS, ESR, CRP, and Numeric Pain Rating Scale (NRS) were then compared between 115 patients with and 80 patients without MC. RESULTS: The EIPS had a confidence of 66.4%, 83% and, 100% for scores of 4, 5 and, 6, respectively, for end plate changes suggesting infection. The mean EIPS was 4.85 ± 1.94 in patients with Modic changes compared to - 0.66 ± 0.49 in patients without Modic changes (p < 0.001). Seventy-eight (67.64%) patients with MC had a score of 6, indicating high infection possibility. There was a difference in the NRS (p < 0.01), ESR (p = 0.05), CRP (p < 0.01), and type of pain (p < 0.01) between patients with and without MC. CONCLUSION: Multimodal imaging showed many radiological signs not easily seen in MRI alone and thus missed in Modic classification. There were distinct radiological differences between EPCs of trauma and infection which allowed the development of an EIPS. The scores showed that 67.64% of our study patients with Modic changes had EPCs resembling infection rather than trauma suggesting the possibility of an infective aetiology and allowing us to propose an alternate theory of 'Primary Endplatitis'.

Aggressive Presentation and Rapid Progression of Osteonecrosis of the Femoral Head After COVID-19.

Background: We aim to report the consecutive patients diagnosed with osteonecrosis of femoral head (ONFH) following recovery from COVID-19 disease and elucidate the unique features of ONFH associated with COVID-19. Methods: Consecutive 22 patients (39 hips) recovered from COVID-19 and presented with ONFH from November 2020 to October 2021 were included. All the patients received corticosteroids as a supportive treatment during COVID-19. Patients were classified into two types based on the type of presentation, namely classic ONFH and rapidly destructive coxarthrosis (RDC) depending on radiographs, MRI, inflammatory markers and hip aspiration findings. Harris hip score was used to evaluate the functional outcome before and after treatment. Results: The mean time to diagnose of ONFH from the onset of hip symptoms was 39.3 days (range 10-90 days). The average duration of onset of hip symptoms after COVID 19 infection was 7.5 months (range 3 - 11 months). The average cumulative dose of methylprednisolone equivalent was 811 mg (range 200-2100 mg) and the average duration of steroid intake was 2.8 weeks. There was significant elevation in the inflammatory markers in RDC group compared to classic ONFH (p < 0.05). The Harris hip score improved from 63.6 ± 23.2 at presentation to 82.6 ± 9.6 after treatment (p < 0.05). Three patients had features of RDC. Among the three patients with RDC, two patients had rapid progression of ONFH and underwent total hip arthroplasty (THA). The third patient is awaiting a THA. Conclusion: ONFH after COVID-19 can have a varied presentation. While the most common presentation is like classical ONFH, some patients can have an acute and aggressive presentation with rapid destruction. They have features like elevated serological markers and extensive periarticular bone and soft tissue edema. A low cumulative dose of steroids in our patients suggests that the COVID-19-associated vasculitis may play a role in the pathogenesis of ONFH.

The phenomenon of vertebral body drift in neurofibromatosis and its implications for surgical safety.

OBJECTIVE: To report on the phenomenon of body drift in neurofibromatosis scoliosis and discuss its implication on surgical safety. MATERIALS AND METHODS: Ten dystrophic neurofibromatosis scoliosis (NF) and ten adolescent idiopathic scoliosis (AIS) were studied by radiographs, CT, and MRI. The curve characteristics and a detailed analysis of the morphology of the apical and three adjacent vertebral segments above and below were done. The coronal alignment and the presence of a drift of the vertebral body in relationship to the lamina were carefully studied in both groups and compared. RESULTS: The mean cobb angle in the NF group was 77.6°, and 63.7° in the AIS group. All the studied vertebra in the NF group had extensive pedicle changes, which were more severe at the apical and periapical regions. Body drift was noted in 29 vertebral segments, with 9/10 of apical segments showing a significant drift. The body drift was associated with significant pedicle dystrophic changes and was independent of the curve magnitude. In comparison, in AIS, no body drift was noted despite a larger deformity and more severe vertebral rotation. CONCLUSION: The 'body drift' phenomenon was unique to neurofibromatosis scoliosis and was secondary to severe pedicle morphology changes. This was present even in curves less than 60° and could result in cord injury while instrumenting the concave pedicle. Therefore, a thorough preoperative assessment and planning by a 3D CT are mandatory.

Can Scoliotic Discs Be Controls for Molecular Studies in Intervertebral Disc Research? Insights From Proteomics.

STUDY DESIGN: Proteomic analysis of human intervertebral discs. OBJECTIVES: To compare the characters of scoliotic discs and discs from magnetic resonance imaging (MRI)-normal voluntary organ donors controls used in disc research employing proteomics and establish "true controls" that can be utilized for future intervertebral disc (IVD) research. METHODS: Eight MRI-normal discs from 8 brain-dead voluntary organ donors (ND) and 8 scoliotic discs (SD) from 3 patients who underwent anterior surgery for adolescent idiopathic scoliosis were subjected to tandem mass spectrometry, and further analysis was performed. RESULTS: Mass spectrometry identified a total of 235 proteins in ND and 438 proteins in the SD group. Proteins involved in extracellular matrix integrity (Versican, keratins KRT6A, KRT14, KRT5, and KRT 13A1, A-kinase anchor protein 13, coagulation factor XIII A chain, proteoglycan 4) and proteins involved in transcription and DNA repair (Von Willebrand factor A domain-containing 3B, eukaryotic initiation factor 2B, histone H4, leukocyte cell-derived chemotaxin 2) were found to be downregulated in SD. Inflammatory proteins (C3, C1S), and oxidative stress response proteins (peroxiredoxin-2,6, catalase, myeloperoxidase, apolipoprotein E) were found to be upregulated in SD. These changes were reflected at the pathway level also. CONCLUSION: Findings of our study confirm that scoliotic discs have an abundance of inflammatory, oxidative stress response proteins, which are either absent or downregulated in the ND group indicating that scoliotic discs are not pathologically inert. Furthermore, this study has established MRI-normal discs from voluntary organ donors as the "true" control for molecular studies in IVD research.

Lumbar Disc Herniation and Preoperative Modic Changes: A Prospective Analysis of the Clinical Outcomes After Microdiscectomy.

STUDY DESIGN: Prospective comparative cohort study. OBJECTIVES: The study aims to elucidate the relationship between Modic endplate changes and clinical outcomes after a lumbar microdiscectomy. METHODS: Consecutive patients undergoing microdiscectomy for lumbar disc herniation (LDH) were prospectively studied. Pre-operative clinical and radiological parameters were recorded. The pain was assessed by Numeric pain rating scale (NPRS), and functional assessment by Oswestry Disability Index (ODI). Minimal clinically important difference (MCID) in outcome was calculated for both the groups. Complications related to surgery were studied. Follow-up was done at 6 weeks, 3 months, 6 months and 1 year. Mac Nab criteria were used to assess patient satisfaction at 1 year. RESULTS: Out of 309 patients, 86 had Modic changes, and 223 had no Modic changes. Both groups had similar back pain (p-value: 0.07) and functional scores (p-value: 0.85) pre-operatively. Postoperatively patients with Modic changes had poorer back pain and ODI scores in the third month, sixth month and 1 year (p-value: 0.001). However, MCID between the groups were not significant (p-value: 0.18 for back pain and 0.58 for ODI scores). Mac Nab criteria at 1 year were worse in Modic patients (p-value: 0.001). No difference was noted among Modic types in the pre-operative and postoperative pain and functional outcomes. Four patients in Modic group (4.7%) and one patient in the non-Modic group (0.5%) developed postoperative discitis (p-value: 0.009). CONCLUSIONS: Preoperative Modic changes in lumbar disc herniation is associated with less favorable back pain, functional scores and patient satisfaction in patients undergoing microdiscectomy.

Anatomical changes in vertebra in dystrophic scoliosis due to neurofibromatosis and its implications on surgical safety.

STUDY DESIGN: Detailed radiological analysis by multimodality imaging. OBJECTIVE: To document anatomical changes jeopardizing instrumentation safety in Neurofibromatosis deformity correction surgeries. MATERIALS AND METHODS: The apical and 3 adjacent vertebral segments above and below amounting to 70 segments in 10 NF scoliosis were studied by radiographs, CT and MRI. The changes in lamina, pedicle and vertebral body that could jeopardize pedicle screw and sublaminar wire placement were documented and changes were appropriately classified. RESULTS: Extensive anatomical changes were noted. These changes were more severe at the apex and independent of the curve severity. Both laminae were normal in only 36 (Type 1), rest had either gross asymmetry in length and shape (Type 2; 21) or also in sloping (Type 3; 13). Of the 140 pedicles, normal pedicles were found only in 48 (Type 1); while they were divergent (Type 2; 4) or abnormally elongated with only thinning (Type 3a; 26); or with sclerosis (3b; 34); or very curved and wavy (3c; 23) and even fractured or indistinct (Type 4; 5). It was notable that 92 of the 140 pedicles were unsuitable for pedicle screws. A unique phenomenon of body drift was identified in 29 segments which could jeopardize screw placement and rib dislocation into the canal was found in 18 segments. CONCLUSION: Gross anatomical changes jeopardizing both sublaminar wire strength and trajectory of pedicle screws were common in NF and independent of curve severity. Therefore, detailed preoperative assessment and planning by a 3D CT are essential.

Missed Intracranial Subdural Hematoma in a Case of Spontaneous Subdural Spinal Hematoma: A Rare Case Report and Literature Review.

INTRODUCTION: Idiopathic spontaneous spinal subdural hematoma (ISSSDH) is uncommon in occurrence, and its association with concomitant intracranial subdural hematoma (ISDH) is very exceptional. Lack of recognition of ISDH in a patient with SSDH can lead to unanticipated events. We report a rare case of ISSSDH and unrecognized ISDH and treated surgically with a good outcome. CASE REPORT: A 71-year-old gentleman presented with features of spinal neurogenic claudication of 2 weeks duration and was diagnosed to have ISSSDH of the lumbar spine based on magnetic resonance imaging (MRI). In view of an impending cauda equina syndrome, he underwent an emergency decompression through a laminectomy, durotomy, and clot evacuation from L2 to L5. The next day, he developed sudden-onset hemiparesis and altered sensorium. The computed tomography (CT) scan of the brain demonstrated an ISDH, for which emergency burr hole evacuation was done.The patient improved rapidly after the surgery and regained his normal power, sensorium, and achieved comfortable ambulation within a week. Follow-up CT of the brain and MRI scan of the spine revealed adequate decompression. Since the CT features of ISDH were of acute on chronic nature, we presume that it had existed before the onset of spinal symptoms. CONCLUSION: Through this very rare case, we highlight the importance of screening the brain pre-operatively in patients who present with sub-acute spontaneous spinal SDH.

Is TIRADS a practical and accurate system for use in daily clinical practice?

AIM: To assess the positive predictive value (PPV) and inter-observer agreement of Thyroid Imaging Reporting and Data System (TIRADS) as described by Kwak et al. MATERIALS AND METHODS: This was a prospective study wherein ultrasound was performed by two radiologists on patients with thyroid nodules >1 cm. The third radiologist interpreted archived images. Ultrasound features and TIRADS category were compared with cytology and surgical histopathology. PPV was calculated for all readers' combined assessment. Inter-observer agreement was calculated using linear weighted kappa. RESULTS: A total of 238 patients with 272 nodules of mean size 2.9 ± 1.7 cm were included. PPV for malignancy was 6.6%, 32%, 36%, 64%, 59%, and 91% for TIRADS 2, 3, 4a, 4b, 4c, and 5 categories, respectively. Inter-observer agreement was substantial [kappa (k) = 0.61-0.80] for assessment of nodule echogenicity, margins, calcification, and shape and good (k = 0.570, P < 0.001) for assessment of composition of the thyroid nodules. Overall agreement between observers was substantial for assigning TIRADS category [multi-rater weighted kappa coefficient (wt k) = 0.721, P < 0.001]. CONCLUSIONS: TIRADS is a simple and practical method of assessing thyroid nodules with high PPV and good inter-observer agreement.