Evaluating the Reliability of Anatomic Landmarks in Safe Lumbar Puncture Using Magnetic Resonance Imaging: Does Sex Matter?

Aim. To determine the level of the conus medullaris-Tuffier's line, and conus medullaris-Tuffier's line distance using imaging and evaluate their relation to age and gender. Methods. We performed a cross-sectional study of 189 adult participants, who underwent MR imaging of lumbosacral spine. Each vertebra was divided into 3 equal segments (upper, middle, and lower), and intervertebral disc space was also assumed as one segment. All segments from T12 upper segment to L5S1 intervertebral disc were numbered consecutively. The position of conus medullaris and Tuffier's line was determined by the vertebral segment or intervertebral disc space at the same level. The patients were stratified into high/low conus medullaris position (cutpoint: L1 middle segment) and short/long conus-Tuffier's distance (cutpoint: 14 segments). Results. Women with low conus were significantly more than men, in patients older than 50 years old (72.7% in females versus 55.3% in males; P < .05), whereas there was not such a sexual dimorphism in patients younger than 50 years old. Similarly, short conus-Tuffier's distance was more frequent among women than men in patients older than 50 years old (59.7% in females versus 39.5% in males; P < .05), whereas there was not any gender difference in patients younger than 50 years old. Conus-Tuffier's distance was negatively correlated with age (r = −0.32, P < .001) in all studied population. Conclusion. Anatomical landmarks vary according to age and gender, with a lower end of conus medullaris in women, so clinicians should use more caution on the identification of the appropriate site for lumbar puncture, particularly in elderly women

Nintinol Self-Expandable Metallic Stenting in Management of Malignant Obstructive Jaundice: A Case Series

Background and Aims: Palliation therapy is the only available therapeutic method for most patients with tumor-induced obstructive jaundice. Metallic stents are now performed percutaneously as an alternative route to the endoscopic approach. It is widely accepted because of its safety, good patency rate, and minimal invasiveness. This study was designed to evaluate the long-term results of metallic self-expandable stent insertion in patients with malignant stenosis of the biliary tree. Methods: It is a longitudinal study of patients with percutaneously biliary stenting from September 2005 to March 2009. The patients had unresectable malignant biliary obstruction with unsuccessful endoscopic stenting and access. Percutaneous transhepatic cholangiogram performed after adequate local anesthesia, under sonographic or fluoroscopic guidance. Stenting or balloon dilation was performed through the hydrophilic guide wire. Among 50 patients, 45 stents were placed in biliary tree stenosis sites. Patients' follow-up was during the first, second, third, and then the sixth month after insertion of biliary stents. Stent patency was considered successful in our patients, when there were no lab results or sonographic appearance of biliary tree obstruction. Results: 10(20) patients' stent placement treatment failed because of unsuccessful technical procedure. The stenosis of biliary tract was complete and passage of guide wire was not possible through the tumor growth. 6 (15 ) patients with successful stent placements died within one month (mean, 22 days). Total serum bilirubin resolved to below 1.5 mg/dl within 30 days for 36 (90) patients with successful stent placements. Early complications not leading to death occurred in 28 of cases. The mean survival time for all patients who underwent stent placement was 140 days (16-420days). The mean patency rate for all stents was 147 days. Conclusions: Percutaneous biliary stenting is a safe procedure with few technical complications and a high success rate of palliation for patients with malignant biliary jaundice. Early complications are mostly managed conservatively and death is mainly due to systemic effects of the malignant disease