The presence of skin marker over the lumbosacral region is a relative contraindication for performing a neuraxial block. Anaesthesiologists are usually hesitant in proceeding with any central regional blocks in those with patients with cutaneous stigmata. There are several literature stating the fact that all types of cutaneous markers are not indicators of spinal dyraphism. Robinson et al from their study in 229 patients suggested that simple cutaneous markers like dimple were not sinister as a sole indicator of occultspinal dyraphism(27). Chern et al conducted a retrospective study of 973 children referred for lumbar ultrasound due to the presence of skin marker of occultspinaldysraphism. Only seven patients (0.007%) in the skin marker group and ten patients (0.057%) in the group having congenital anomalies had occultspinal dyraphism. They concluded that presence of skin markers are not reliable and were not conclusive of occultspinaldysraphism.(28). In our study, 41 patient had some skin marker and only one patient in this group had an abnormal scan. Neuraxial blocks were performed in this group safely as the ultrasound screening revealed normal anatomy. Hence it would be worthwhile doing a screening ultrasound scan when in doubt in the presence of a skin marker.
Controversy exists in regard to the most appropri- ate neuroimaging modality to assess occultspinaldysraphism in the newborn. We used the methods of decision analysis to compare the long-term costs and health outcomes of various imaging strategies for children with suspected occultspinaldysraphism. We found that the choice of imaging strategy de- pends on the underlying risk of occultspinal dysra- phism. In low-risk children with intergluteal dimple or in newborns of diabetic mothers (pretest proba- bility: 0.3%– 0.34%), the US strategy was the most effective with an incremental cost-effectiveness ratio of $55 100 per QALY gained. For children with lum- bosacral dimples, who have a higher pretest proba- bility of 3.8%, US was less costly and more effective than the other 3 strategies considered.
indicative of spinaldysraphism are dermal changes such as areas with marked hirsutism or pigmentation on and surrounding the area and level of the spinaldysraphism, however, they are not as common in adults as they are in children, accounting for 35.6% in adult cases [1,5,10]. Based on these findings and the mild pain which improved with analgesia, either conservative treatment was determined in combination with clinical symptoms or further diagnostic measure such as Somatosensory evoked potentials was Ordered and the result was. Presenting complaints of TCS are non-specific, encompassing lower back pain, sensory deficits, motor weakness, and sphincter incompetence [1,3,5-8]. Adult onset TCS is usually precipitated by physical exertion, such as back flexion, washing dishes, or receiving trauma to the back [9,10]. Furthermore, spine abnormalities such as degenerative spinal stenosis are an aggravating factor for the emergence of TCS symptoms . Suspicion of TCS as a differential diagnosis is low, due to the subtle and non-specific presenting complaint, insidious and chronic onset, and deficits not respecting the dermatomoal and myotomal distribution pattern; hence they are initially diagnosed as one of the common orthopedic, neurological, or genitourinary complaint such as lumbosacral degenerative disc herniation . The initial complaint is usually lower back pain, which radiated to the lower limbs in a non-dermatomal pattern chronically; radicular pain distribution is
Occultspinaldysraphism should be suspected in case of poor PEG responder constipation, even when evident sa- cral abnormalities on the physical examination are not detected. In this case, instrumental tests (i.e. abdominal x-ray/MRI) should be performed. Particularly abdominal x-ray is a first level test, cost-effective and easy to per- form which can give useful information about rachis morphology.
Spinal metastases occur 20 times more commonly than primary tumors of spine. Five to ten percent of cancer patients develop spinal metastasis . Spinal metastasis are often multiple and are frequently seen late in the course of disease, in which brain or visceral metastasis are also evident. Intramedullary spinal cord metastases (ISCMs) represent only 0.9% to 2.1% of autopsy cases in patients with cancer . One third of adult spinal cord tumors are intramedullary and rest are extramedullary. Of the tumors metastasizing to the spinal cord lung car- cinoma is the most common accounting for 50% followed by breast carcinoma, Lymphoma, melanoma, colo- rectal carcinoma, Hodgkin disease, head and neck carcinoma and leukemia  . Primary tumors less com- monly reported to metastasize to spine include schwannoma, mesothelioma, merkel tumor, plasmacytoma, tera- toma, as well as basal cell, parotid, nasopharyngeal, laryngeal, esophageal, gall bladder, pancreas, ovarian, en- dometrial, and urinary bladder tumors. Only about 2% of spinal metastasis is of unknown origin .
There are several options for CRC screening falling into two broad categories: stool tests and structural exams. Stool tests include fecal occult blood tests (FOBt) and tests for exfoliated DNA. Structural exams include flexible sig- moidoscopy, total colonoscopy and computed tomo- graphic colonography (CTC). FOBt is the only screening method with a documented CRC mortality reduction in randomized controlled trials. The efficacy of strategies based on repeated guaiac FOBt has been established in three randomized trials and one non-randomized con- trolled trial [6-9]. A meta-analysis after several rounds of these continuing trials showed a CRC mortality reduction of 14% during a 10-year screening period.
searched our data base for all examinations performed in the set- ting of spinaldysraphism assessment, as well as for appropriate gestational age–matched controls. The image quality had to be good, consisting of at least 3 orthogonal T2-weighted HASTE se- ries of the fetal brain with limited fetal motion, allowing adequate performance of the outcome measurements. The primary selec- tion and review of images was performed by a single pediatric radiologist (M.A.) with ⬎ 3 years of experience in fetal MR imag- ing. The main exclusion criteria were twin pregnancy, syndromal pathology, fetal hydrops, or anhydramnios. The number of pa- tients and individual reasons for exclusion are shown in On-line Table 2. This exclusion left data from 349 MR imaging examina- tions of a total of 1006, including 274 examinations in 246 control fetuses. These data illustrate that some fetuses were scanned more than once. Additionally, we included 52 MR imaging examina- tions in fetuses with OSD, of whom 23 had a repeat MR imaging examination after the operation. The eligibility criteria for fetal surgery were those used in the MOMS trial. 12
In patients with NMOSD, the spinal lesions result in damage to spinal neurons that send afferent fibers to the cerebellum. These impaired spinal neurons may lead to structural damage in the corresponding cerebellar regions via a mechanism of Walle- rian degeneration through spinal-cerebellar circuitry. The axonal degeneration may better account for the NAGM reduction in these cerebellar cortices in patients with NMOSD with spinal le- sions. Spinal neurons can directly connect to cerebellar nuclei, especially the interposed nucleus, via the spinocerebellar tracts and spinoreticulocerebellar tracts. 23 Moreover, the cerebellar nu-
This study did not find any significant association be- tween occult HBV and the variables tested such as age, sex, alcohol use, smoking, sharing of sharps scarification marks/tattoos and number of lifetime sexual partners. This is most likely because of the small number (19) of individuals in which we detected HBV DNA. This num- ber was probably too small for reliable statistical ana- lysis. However all those with OBI in this study were found to be males, mostly less than 36 years.
I n the fall of 2004, the province of Ontario launched a pilot study of colorectal cancer (CRC) screening to evaluate fecal occult blood testing (FOBT) as the initial test in the process. Fecal occult blood testing would be followed by colonoscopy for those receiving positive FOBT results. The primary goals of the study were to assess the likely use of the test and the positive test rates if a province-wide, population-based program were to be launched; to assess various approaches to promoting screening, mainly through primary care phy- sicians and regional public health units; and to evaluate how receptive the public would be to testing. One part of the pilot study was an assessment of people’s aware- ness of FOBT and CRC screening generally and of their readiness to contemplate undergoing FOBT.
HCC patients living in endemic areas for HBV were frequently found positive for HBsAg and/or anti-HBc antibodies and this strong relationship was the first epi- demiological evidence of HBV-related oncogenic trans- formation . Among our 40 HCC patients with different serological patterns for HBV infection, the prevalence of occult HBV infection was 10% in both anti-HBs and anti-HBc positive cases, and 0% in cases negative for all markers. The overall prevalence was sig- nificantly higher for those positive for anti-HBc alone or with anti-HBs than for those negative for all markers. Data presented here sowed that out of the intrahepatic HBV DNA positive cases, 56% were only anti-HBc-IgG positive, while 44% were both anti-HBc-IgG and anti- HBs positive. A higher frequency of HBV-DNA, among anti-HBc positive patients 46% than in anti-HBc nega- tive patients (20%) has previously reported . We sug- gested that while HBV is not the only factor in HCC development in Egypt, it is still one of the major risks.
from primary diffuse leptomeningeal gliomatosis, which has been defined as a leptomeningeal-based glioma that has no ‘‘direct connection to the brain or spinal cord and . . . [is] . . . unaccompanied by a parenchymal neoplasm that could serve as a source of meningeal dissemination’’ (10). We found only two cases of primary diffuse leptomen- ingeal oligodendrogliomatosis reported in the lit- erature (8, 9). It has been postulated that gliomas that primarily involve the subarachnoid space arise from leptomeningeal heterotopias (4). These con- genital anomalies consist of small islands and nests of glial tissue within the subarachnoid space and occur in approximately 1% of healthy individuals and 25% of patients with other congenital brain malformations (11).
of patients without the number of patients with neck dis- section. Seven studies involved the cases of patients with neck dissection, 4 of which included occult metastases. The overall metastases rate was defined as the ratio between the number of pathological node positive (pN + ) cases and total cases. During the follow-up period, patients without neck dissection initially presenting with regional metastases or recurrence would also be considered as pN + cases. The occult metastases rate was defined as the ratio between the number of cN-pN + cases and total cN0 cases. 26 Detailed information
occur with normal physiological activities. Whatever imaging shows in the neural foramina of patients who are in a recumbent position, the anatomic relationships in the neural foramina are most likely different as the patient stands and carries out normal activities. In patients with signs and symptoms of lateral spinal ste- nosis, the presence of a radial tear of the annu- lus fibrosus or advanced degenerative changes in the intervertebral disk is indicative of an in- creased risk that the nerve root in the neural foramen may become intermittently com- pressed during motion or during load bearing. Nerve root contact when demonstrated by im- aging may be relieved when the patient as- sumes a different position. Some moments, such as flexion, tend to relieve more stenosis than they produce, while others, such as exten- sion, tend to produce more stenosis than they relieve. However, this study suggests that when imaging demonstrates nerve root compression, it is less likely that the stenosis will be relieved or resolved by normal activity. In all motion segments with advanced disk degeneration, nerve root contact or compression occurred at some time during the load study. On the other hand, when imaging demonstrates no nerve root effect, the nerve root may be intermittently compressed during daily activities. If CT or MR imaging show narrowing of the neural foramen without nerve root compression, that foramen may be critically narrowed so as to cause en- trapment when loads are applied. The study suggests that a radial tear or advanced degen- eration of the intervertebral disk increases the risk of occult stenosis because it changes the stiffness or mobility of the motion segment to specific loads or moments.
Retethering of spinal cord is a known phenomenon after primary surgery for tethered cord release caused due to various conditions like MMC, LMM etc. Interpretation of MRI is of paramount importance which is missed sometimes leading to non-recognition of pathology in the course of disease. Good release of tethered cord at first instance prevents recurrence in many patients and it has to be done by trained and experienced personnel, who have trained in this field. The challenge lies not only in the release of tethered cord but also in identifying patients with RTC. Second surgery has good outcome in the majority of patients especially in those with early signs and symptoms of retethering and also requires mandatory follow-up after second surgery with multi-disciplinary team. Awareness should be made among referral population, general practitioners, pediatricians, and obstetricians that treatment of RTC should be carried out by trained neurosurgeons, especially in developing countries where there are no specific referral guidelines. Finally to conclude, “an experience in handling such cases would give better results” and requires long term followup, rehabilitation and importance of at least an annual checkup for preventing and managing kidney damage in all patients of tethered cord release.
The primitive filum extends caudally from the apex of the primitive conus to the 29th- 30th vertebra. After involution of the distal cord to the filum terminale, the newly formed conus medullaris lies opposite the lower coccygeal segments. Thereafter, the spinal cord and filum do not shorten further. Rather, they elongate and thicken by interstitial growth. The caudal cell mass formed by notochord, mesoderm, and neural tissue simply segments into somites to form the sacral, coccygeal, and tail vertebrae. Retrogressive differentiation then leads to reduction of most of these segments with loss of the tail. Thereafter the vertebral column elongates with growth and grows faster than the cord. All further "ascent" of the cord results from disproportionately greater longitudinal growth of the vertebrae, not involution; the bones simply grow faster and descend away from the cord.
Background: SpinalDysraphism includes a spectrum of congenital disorders caused by incomplete or abnormal closure of the neural tube during early embryogenesis. As a result, fusion of the midline spinal elements is either absent or incomplete.MRI is an excellent imaging modality for visualizing the spinal cord of patients of all ages.It is the imaging modality of choice for defining complex spinaldysraphism. Most attractive features of MRI that made it superior to conventional radiography and CT myelography are its ability to image the cord directly without the use of contrast or ionising radiation, absence of bone artefacts and its multiplanar capability. Methods: A Cross-sectional Observational study was done in 32 patients. Patients who were diagnosed or provisionally diagnosed as cases of spinaldysraphism, irrespective of age and sex, based on the Clinical profile and imaging profile as preliminary findings on radiographs/Ultrasonography and incidentally detected cases on either Radiographs, CT, USG or MRI were included in our study. Results: In the pre CT era the combination of a precise clinical pattern with x ray images of the spine could prompt a suspicion of SpinalDysraphism. Ultrasonographic evaluation for spina bifida includes both spinal and cranial imaging. Computed tomography better showed osseous abnormalities associated with the spinal congenital malformations.MR imaging is considered as the primary imaging modality in the evaluation of the paediatric spinal canal. Congenital anomalies as well as neoplastic, inflammatory, and traumatic disorders can be reliably evaluated with MR imaging. Conclusions: MR imaging clearly reveals an excellent tissue differentiation, especially of lipomatous tissue. The reproducible and comprehensive section planes, as well as the relative operator-independence are also well appreciated facts. MRI is a single safe, non-invasive and quick method of describing the gamut of findings in patients with spinaldysraphism.
Isoflurane had always been known to have neuroprotective properties. Sevoflurane by virtue of its low solubility provides rapid onset and offset of an aesthesia, thus facilitating early postoperative evaluation of the patients especially in the neurosurgical procedures. However superior role of sevoflurane to isoflurane in pediatric patients requiring intermediate lasting anaesthesia remains controversial. Therefore the aim of this prospective comparative randomized study was to sevoflurane and isoflurane in paediatric patients undergoing surgery for spinaldysraphism on the basis of early post recovery outcomes, pain, intraoperative and postoperative hemodynamics, and postoperative side effects of both the agents. Materials and Methods: 60 patients scheduled for spinaldysraphism surgery of ASA physical status I & II, of either sexes, aged 6 years, were divided into two groups. After I.V. induction maintenance gent as isoflurane for Group I (n=30), and sevoflurane for Group II (n=30). The primary end points being post-anaestheisa recovery, extubation time, discharge readiness in PACU and emergence agitation, While the secondary end points included and postoperative Heat Rate, noninvasive blood pressure and SpO 2 and postoperative
On physical examination, she was mildly anemic, normotensive and wasting of calf muscles. There was an ill defined, non tender and firm lump on the right paravertebral region at the level of D11‑L1 [Figure 1]. On neurological examination, there was a marked loss of muscle function with grades 1/5 strength in both lower extremity muscles with increased the muscle tone. Ankle and knee reflexes were exaggerated. Planter reflex was extensor and both ankle and patellar clonus present. All modalities of sensations diminished from D11. The X‑ray of dorso‑lumber region showed bony destruction of transverse process of L1 and pedicles of D12 and L1 [Figure 2]. A magnetic resonance imaging (MRI) scan showed a huge mass involving the right para spinal area and spinal cannel at D11‑L1, compressing the spinal cord (D11‑D12) and destroyed the posterior arches of the vertebra (D12‑L1) [Figure 3a and b].