Bipolar Lumbar Radiofrequency Medial Branch Neurotomy in a Patient with Deep Brain Stimulation Implant.

Chronic axial lower back pain is one of the most common conditions that patients seek medical attention for in pain practices. About 15 to 40% of axial lower back pain is due to facet-mediated pain. Diagnostic blocks of the medial branch reliably identify the facet joint as the pain generator and offer a prognostic factor for response to radiofrequency neurotomy of the identified facet joints resulting in profound pain relief. However, deep brain stimulation implants have been considered a contraindication for neurotomy. We present an illustrative case of a patient with deep brain stimulation system treated with bipolar medial branch neurotomy using a two-needle technique.

Bedside USG-Guided Paracentesis - A Technical Note for Beginners.

Paracentesis is a routinely performed low-risk daycare procedure most commonly performed in patients with cirrhosis. Although uncommon, devastating bleeding complications may occur, particularly in patients with coagulopathy. Hence to avoid any such complication, it is important for the intervention radiologists, as well as clinicians, particularly beginners, to have basic knowledge of the major anterior abdominal wall arteries, their course, and their sonographic appearance. Here, we briefly describe the relevant abdominal wall anatomy and sonographic planes to use for paracentesis.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis.

Objective: Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS). Methods: Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality. Results: Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified "PMV > 24 hrs" (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke's R2 0.38). Conclusions: Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

Safety Evaluation of Cervical Dorsal Instrumentation in Geriatric Patients: Experience at a Level 1 Center for Spinal Surgery-A Single Center Cohort Study.

Objective: Dorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery. Methods: In this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden. Results: In total, 153 patients were identified and included. The mean age of patients was 78 years (SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality. Conclusion: Our data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

Suppurative Pylephlebitis With Portal Vein Abscess Mimicking Portal Vein Thrombosis: A Report of Two Cases.

Suppurative pylephlebitis, that is, infected thrombosis of the portal vein and its branches is a rare condition with a high incidence of mortality and is often difficult to diagnose. We report two cases of suppurative pylephlebitis secondary to acute pancreatitis wherein the whole of the portal vein and its branches were transformed into an abscess cavity. The diagnosis was made after pus was seen coming out while the patient was taken up for portal vein thrombolysis. The pus was drained and the cavity was completely evacuated leading to recovery from this infection. These two cases highlight the fact that suppurative pylephlebitis is rare and extremely difficult to diagnose as it mimics portal vein thrombosis, but a high degree of suspicion in critically ill patients with thrombus-like appearance in portal vein having a uniform and homogeneous portal venous content on magnetic resonance imaging not responding to antibiotic therapy may be considered for aspiration for differentiating from thrombus and management.

Heat-Shock Induces Granule Cell Dispersion and Microgliosis in Hippocampal Slice Cultures.

Granule cell dispersion (GCD) has been found in the dentate gyrus (dg) of patients with temporal lobe epilepsy (TLE) and a history of febrile seizures but was also recently observed in pediatric patients that did not suffer from epilepsy. This indicates that GCD might not always be disease related, but instead could reflect normal morphological variation. Thus, distribution of newborn granule cells within the hilar region is part of normal dg development at early stages but could be misinterpreted as pathological GCD. In turn, pathological GCD may be caused, for example, by genetic mutations, such as the reeler mutation. GCD in the reeler mutant goes along with an increased susceptibility to epileptiform activity. Pathological GCD in combination with epilepsy is caused by experimental administration of the glutamate receptor agonist kainic acid in rodents. In consequence, the interpretation of GCD and the role of febrile seizures remain controversial. Here, we asked whether febrile temperatures alone might be sufficient to trigger GCD and used hippocampal slice cultures as in vitro model to analyze the effect of a transient temperature increase on the dg morphology. We found that a heat-shock of 41°C for 6 h was sufficient to induce GCD and degeneration of a fraction of granule cells. Both of these factors, broadening of the granule cell layer (gcl) and increased neuronal cell death within the gcl, contributed to the development of a significantly reduced packaging density of granule cells. In contrast, Reelin expressing Cajal-Retzius (CR) cells in the molecular layer were heat-shock resistant. Thus, their number was not reduced, and we did not detect degenerating CR cells after heat-shock, implying that GCD was not caused by the loss of CR cells. Importantly, the heat-shock-induced deterioration of dg morphology was accompanied by a massive microgliosis, reflecting a robust heat-shock-induced immune response. In contrast, in the study that reported on GCD as a non-specific finding in pediatric patients, no microglia reaction was observed. Thus, our findings underpin the importance of microglia as a marker to distinguish pathological GCD from normal morphological variation.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications.

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

MRI imaging of displaced meniscal tears: Report of a case highlighting new potential pitfalls of the MRI signs.

Magnetic resonance imaging (MRI) has been found to be an excellent imaging tool for meniscal injuries. Various MRI signs have been described to detect displaced meniscal injuries, specifically the bucket-handle tears. Although these signs are quite helpful in diagnosing meniscal tears, various pitfalls have also been reported for these signs. Double anterior cruciate ligament (ACL) sign refers to presence of a linear hypointense soft tissue anterior to the ACL, which represented the flipped bucket-handle tear of the meniscus. Disproportional posterior horn and flipped meniscus signs represent asymmetrically thickened horns of the menisci due to overlying displaced meniscal fragments. We report a case wherein MRI of the knee showed tear and displacement of the medial patellofemoral ligament (MPFL) and vastus medialis complex, medial collateral ligament (MCL), and posterior cruciate ligament (PCL) mimicking these signs. To our knowledge, internally displaced MPFL and MCLs have not been described as mimics for displaced meniscal fragments.

Idiopathic spinal cord herniation.

Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy. This condition has recently seen an increased frequency of diagnosis, possibly due to increased awareness and the use of magnetic resonance (MR) imaging. ISCH is characterised by herniation of the thoracic spinal cord through an anterior or anterolateral dural defect. Patients usually present with a Brown-Séquard-like syndrome, which is gradually progressive and may evolve into severe paraparesis. This disease has a characteristic radiological appearance, and in most cases, excellent postsurgical outcome. We report ISCH and its imaging appearance in a 31-year-old woman with classical presentation, and discuss the current concepts regarding the aetiopathogenesis, radiological features and management of the disease.