Osteoporotic Sacral Insufficiency Fractures in a Patient With Alternating Buttock Pain: A Case Report

Lower back and buttock pain in older adults is often attributed to lumbar or hip degenerative pathology.1 However, in patients with multimorbidity, particularly those with malignancy or osteoporosis, broader causes must be considered. We present a 71-year-old female with three episodes of intractable, alternating buttock pain over 12 months, diagnosed with bilateral sacral insufficiency fractures (SIFs) upon orthopaedic consultation. This case illustrates the diagnostic challenge of SIFs and the importance of multidisciplinary management in fragility fracture care

The effect of obesity upon the lumbar spine

Back pain is a massive global public health problem with multiple contributing factors including obesity. Obesity is thought to be linked to back pain through mechanical factors. However, obesity also causes a systemic low-grade inflammatory milieu. This would suggest a possible biochemical link between obesity, intervertebral disc degeneration, and back pain. Furthermore, the relationship between obesity and the clinical presentation of spine patients is unclear. This thesis aims to examine the effect of and relationship between obesity, the intervertebral discs, and back pain from biochemical, clinical, and epidemiological perspectives In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-α and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine. In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-α and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine.This thesis is not currently available via ORA

Total uncinectomy of the cervical spine with an osteotome: technical note and intraoperative video

Total uncinate process resection or uncinectomy is often required in the setting of severe foraminal stenosis or cervical kyphosis correction. The proximity of the uncus to the vertebral artery, nerve root, and spinal cord makes this a challenging undertaking. Use of a high-speed burr or ultrasonic bone dissector can be associated with direct injury to the vertebral artery and thermal injury to the surrounding structures. The use of an osteotome is a safe and efficient method of uncinectomy. Here the authors describe their technique, which is illustrated with an intraoperative video.</jats:p

Is exploration mandatory in penetrating zone II neck injuries?

BACKGROUND: A policy of mandatory neck exploration for zone II injuries deep to platysma was promoted in the 1950s and was associated with a reduction in mortality when compared with expectant or delayed exploration. Recently many trauma centres have been practising selective neck exploration using physical examination and imaging to stratify patients to different management strategies. In the Auckland region, patients with penetrating zone II injury deep to platysma have been managed with mandatory neck exploration. As penetrating injuries in the Auckland region are caused by a range of sharp objects, with gunshot wounds rare, outcomes of management of zone II neck injuries in this population warrant investigation. The aim of this study was to determine the rate of therapeutic neck exploration in patients with penetrating zone II neck injury in the Auckland region and to suggest optimum management strategies for such injuries. METHODS: Retrospective audit of all patients presenting to Auckland and Middlemore Hospitals, Auckland, New Zealand, between 1995 and 2005 was carried out. Review of electronic clinical records and operation notes was also carried out. RESULTS: An overall positive neck exploration rate of 25% was obtained (87% for patients with hard signs on physical examination). Physical examination had a sensitivity of 93% and a positive predictive value of 87% in this case series. Neck exploration was not associated with known complications or missed injuries. CONCLUSION: In the Auckland setting, physical examination would appear to be a safe and reliable method for the stratification of patients for either operative or conservative management

Mapping MRI-Based Grading Systems for Cervical Spinal Cord Compression: A Scoping Review

Cervical spinal cord compression (c-SCC) is a significant radiological finding associated with neurological impairment, necessitating early and accurate identification to optimise clinical outcomes. While MRI is the gold standard for assessing c-SCC, there is no universally accepted grading system to standardise severity classification. Various MRI-based grading scales exist, however, they differ in criteria, reliability, and clinical application. This scoping review aims to map existing MRI-based classification methods, highlighting methodological differences, validation efforts, and gaps in standardisation to inform future consensus efforts

Immobilisation versus early ankle movement for treating acute lateral ankle ligament injuries in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects (benefits and harms) of immobilisation compared with early movement protocols for acute lateral ankle ligament injuries

Obesity increases the odds of intervertebral disc herniation and spinal stenosis; an MRI study of 1634 low back pain patients

PURPOSE: The objective of this study was to examine the relationships between BMI and intervertebral disc degeneration (DD), disc herniation (DH) and spinal stenosis (SS) using a large, prospectively recruited and heterogeneous patient population.METHODS: Patients were recruited through the European Genodisc Study. An experienced radiologist scored MRI images for DD, DH and SS. Multivariate linear and logistic regression analyses were used to model the relationship between these variables and BMI with adjustment for patient and MRI confounders.RESULTS: We analysed 1684 patients with a mean age of 51 years and BMI of 27.2 kg/m 2. The mean DD score was 2.6 (out of 5) with greater DD severity with increasing age (R2 = 0.44). In the fully adjusted model, a 10-year increase in age and a 5 kg/m 2 increase in BMI were associated, respectively, with a 0.31-unit [95% CI 0.29,0.34] and 0.04-unit [CI 0.01,0.07] increase in degeneration. Age (OR 1.23 [CI 1.06,1.43]) and BMI (OR 2.60 [CI 2.28,2.96]) were positively associated with SS. For DH, age was a negative predictor (OR 0.70 [CI 0.64,0.76]) but for BMI (OR 1.19 [CI 1.07,1.33]), the association was positive. BMI was the strongest predictor of all three features in the upper lumbar spine. CONCLUSIONS: While an increase in BMI was associated with only a slight increase in DD, it was a stronger predictor for DH and SS, particularly in the upper lumbar discs, suggesting weight loss could be a useful strategy for helping prevent disorders associated with these pathologies.</p