Patients with chronic non-specific low back pain (LBP) walk with more synchronous (in-phase) horizontal pelvis and thorax rotations than controls. Low thorax–pelvis relative phase in these patients appears to result from in-phase motion of the thorax with the legs, which was hypothesized to affect arm swing. In the present study, gait kinematics were compared between LBP patients with lumbar disc herniation and healthy controls during treadmill walking at different speeds and with different step lengths. Movements of legs, arms, and trunk were recorded. The patients walked with larger pelvis rotations than healthy controls, and with lower relative phase between pelvis and thorax horizontal rotations, specifically when taking large steps. They did so by rotating the thorax more in-phase with the pendular movements of the legs, thereby limiting the amplitudes of spine rotation. In the patients, arm swing was out-of phase with the leg, as in controls. Consequently, the phase relationship between thorax rotations and arm swing was altered in the patients.
Gait coordination; Trunk movements; Relative phase; Low back pain; Arm swing
In the absence of external forces, the largest contributor to intervertebral disc (IVD) loads and stresses is trunk muscular activity. The relationship between trunk posture, spine geometry, extensor muscle activity, and the loads and stresses acting on the IVD is not well understood. The objective of this study was to characterize changes in thoracolumbar disc loads and extensor muscle forces following anterior translation of the thoracic spine in the upright posture. Vertebral body geometries (C2 to S1) and the location of the femoral head and acetabulum centroids were obtained by digitizing lateral, full-spine radiographs of 13 men and five women volunteers without previous history of back pain. Two standing, lateral, full-spine radiographic views were obtained for each subject: a neutral-posture lateral radiograph and a radiograph during anterior translation of the thorax relative to the pelvis (while keeping T1 aligned over T12). Extensor muscle loads, and compression and shear stresses acting on the IVDs, were calculated for each posture using a previously validated biomechanical model. Comparing vertebral centroids for the neutral posture to the anterior posture, subjects were able to anterior translate +101.5 mm±33.0 mm (C7–hip axis), +81.5 mm±39.2 mm (C7–S1) (vertebral centroid of C7 compared with a vertical line through the vertebral centroid of S1), and +58.9 mm±19.1 mm (T12–S1). In the anterior translated posture, disc loads and stresses were significantly increased for all levels below T9. Increases in IVD compressive loads and shear loads, and the corresponding stresses, were most marked at the L5–S1 level and L3–L4 level, respectively. The extensor muscle loads required to maintain static equilibrium in the upright posture increased from 147.2 N (mean, neutral posture) to 667.1 N (mean, translated posture) at L5–S1. Compressive loads on the anterior and posterior L5–S1 disc nearly doubled in the anterior translated posture. Anterior translation of the thorax resulted in significantly increased loads and stresses acting on the thoracolumbar spine. This posture is common in lumbar spinal disorders and could contribute to lumbar disc pathologies, progression of L5–S1 spondylolisthesis deformities, and poor outcomes after lumbar spine surgery. In conclusion, anterior trunk translation in the standing subject increases extensor muscle activity and loads and stresses acting on the intervertebral disc in the lower thoracic and lumbar regions.
Posture; Sagittal alignment; Intervertebral disc; Biomechanics; Spinal load
In the past decade, the endoscopic transnasal technique has been broadly applied as a feasible and less invasive approach to the skull base. The adaptability of the endoscopic technique allows a case-specific approach in order to minimize both endonasal and cranio-cerebral manipulation; therefore it can be also used in patients complaining exceptional skull base lesions and in weak patients. The objective of this paper is to present the first case of intracerebral bullet removal using a pure endoscopic transnasal route through a custom made unilateral craniectomy.
A 59-year-old patient was admitted to the emergency department after a gunshot injury to the head, thorax, abdomen, and pelvis. Admission Glasgow Coma Scale was 7. Brain computed tomography (CT) scan highlighted a right occipital hole defect due to perforative impact, intracerebral dislocations of bone fragments, right intracerebral and subdural hematoma, and midline shift to the left side; the bullet was localized in the right frontal lobe and its tip was in contact with the ethmoid roof.
The patient underwent emergency decompressive craniectomy and evacuation of the subdural hematoma and abdominal explorative laparotomy, ileum resection, and gastrorrhaphy. After 1 month, the patient underwent endoscopic transnasal removal of the bullet and skull base reconstruction due to cerebrospinal fluid infection. The postoperative course was uneventful and he has done well in follow-up with no evidence of cerebrospinal fluid leak and preservation of olfaction.
The adaptability of the endoscopic transnasal technique offers patients complaining exceptional skull base lesions a case-specific strategy minimizing morbidity and postoperative stay.
Bullet removal; endoscopic; intracerebral; transnasal
Standing in an erect position is a human property. The pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis.
Biomechanical adaptation of the spine in pathology
In case of pathological kyphosis, different mechanical compensations may be activated. When the spine remains flexible, the hyperextension of the spine below or above compensates the kyphosis. When the spine is rigid, the only way is rotating backward the pelvis (retroversion). This mechanism is limited by the value of PI. Hip extension is a limitation factor of big retroversion when PI is high. Flexion of the knees may occur when hip extension is overpassed. The quantity of global kyphosis may be calculated by the SSA. The more SSA decreases, the more the severity of kyphosis increases. We used Roussouly’s classification of lumbar lordosis into four types to define the shape of the spine. The forces acting on a spinal unit are combined in a contact force (CF). CF is the addition of gravity and muscle forces. In case of unbalance, CF is tremendously increased. Distribution of CF depends on the vertebral plate orientation. In an average tilt (45°), the two resultants, parallel to the plate (sliding force) or perpendicular (pressure), are equivalent. If the tilt increases, the sliding force is predominant. On the contrary, with a horizontal plate, the pressure increases. Importance of curvature is another factor of CF distribution. In a flat or kyphosis spine, CF acts more on the vertebral bodies and disc. In the case of important extension curvature, it is on the posterior elements that CF acts more. According to the shape of the spine, we may expect different degenerative evolution: (a) Type 1 is a long thoraco-lumbar kyphosis and a short hyperlordosis: discopathies in the TL area and arthritis of the posterior facets in the distal lumbar spine. In younger patients, L4 S1 hyperextension may induce a nutcracker L5 spondylolysis. (b) Type 2 is a flat lordosis: Stress is at its maximum on the discs with a high risk of early disc herniation than later with multilevel discopathies. (c) Type 3 has an average shape without characteristics for a specific degeneration of the spine. (d) Type 4 is a long and curved lumbar spine: this is the spine for L5 isthmic lysis by shear forces. When the patient keeps the lordosis curvature, a posterior arthritis may occur and later a degenerative L4 L5 spondylolisthesis. Older patients may lose the lordosis curvature, SSA decreases and pelvis tilt increases. A widely retroverted pelvis with a high pelvic incidence is certainly a previous Type 4 and a restoration of a big lordosis is needed in case of arthrodesis.
The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution. This shape is oriented by a shape pelvis parameter, the pelvis incidence. In case of pathology, this constant parameter is the only signature to determine the original spine shape we have to restore the balance of the patient.
Lumbar lordosis; Spino-sacral angle; Thoracic kyphosis; Pelvic incidence; Pelvic tilt; Sacral slope; Sagittal balance; Pathological balance
Sacroiliac syndrome is characterized by buttock and lower limb pain that is associated with decreased mobility and tenderness of the sacroiliac joints. It can occur concomitantly with disorders of the lumbar spine and may go unrecognized until these other conditions are successfully treated. It may sometimes be associated with post-surgical immobilization of the spine and pelvis. A case is presented illustrating successful treatment by chiropractic manipulation.
low-back pain; sacroiliac joint; manipulation
Nephrolithiasis is a common condition with symptoms similar to common mechanical lesions of the lumbar spine and pelvis. The purpose of this report is to outline a case of nephrolithiasis that closely mimicked sacroiliac joint syndrome in subjective report, objective findings, and reduction of symptoms with spinal manipulation.
A 41-year-old obese male patient with mild pain over the left posterior sacroiliac joint, penile paresthesia, and the penile sensation of urinary urgency presented for chiropractic care. Subjective history and objective evaluation suggested sacroiliac joint syndrome.
Intervention and Outcome
A trial of conservative management including spinal manipulation was initiated. Following each treatment, the patient reported temporary relief of all symptoms (4 hours to 2 days). After unsuccessful permanent resolution of symptoms, a urinalysis was performed; and a follow-up computerized tomography scan revealed a large renal calculus obstructing the left ureter. Laser lithotripsy produced obliteration of the stone and complete resolution of symptoms.
This report outlines the potential overlap of symptoms of visceral and somatic lesions in both presentation and response to care. In this case, a favorable response to spinal manipulation masked the most likely underlying symptom generator. This encounter demonstrates the potential need for further clinical examination in the instance of the unresponsive mechanical lesion. This report also supports the need for future research into spinal manipulation as a possible adjunct for visceral pain management.
Spinal manipulation; Renal calculi; Nephrolithiasis; Chiropractic
Proper management of cervical spine injuries in men's lacrosse players depends in part upon the ability of the helmet to immobilize the head.
To determine if properly and improperly fitted lacrosse helmets provide adequate stabilization of the head in the spine-boarded athlete.
Sports medicine research laboratory.
Patients or Other Participants:
Eighteen healthy collegiate men's lacrosse players.
Participants were asked to move their heads through 3 planes of motion after being secured to a spine board under 3 helmet conditions.
Main Outcome Measure(s):
Change in range of motion in the cervical spine was calculated for the sagittal, frontal, and transverse planes for both head-to-thorax and helmet-to-thorax range of motion in all 3 helmet conditions (properly fitted, improperly fitted, and no helmet).
Head-to-thorax range of motion with the properly fitted and improperly fitted helmets was greater than in the no-helmet condition (P < .0001). In the sagittal plane, range of motion was greater with the improperly fitted helmet than with the properly fitted helmet. No difference was observed in helmet-to-thorax range of motion between properly and improperly fitted helmet conditions. Head-to-thorax range of motion was greater than helmet-to-thorax range of motion in all 3 planes (P < .0001).
Cervical spine motion was minimized the most in the no-helmet condition, indicating that in lacrosse players, unlike football players, the helmet may need to be removed before stabilization.
stabilization; emergency management; protective equipment
Compensatory trunk movements during gait, such as a Duchenne limp, are observed frequently in subjects with osteoarthritis of the hip, yet angular trunk movements are seldom included in clinical gait assessments. Hence, the objective of this study was to quantify compensatory trunk movements during gait in subjects with hip osteoarthritis, outside a gait laboratory, using a body-fixed-sensor based gait analysis. Frontal plane angular movements of the pelvis and thorax and spatiotemporal parameters of persons who showed a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp.
A Body-fixed-sensor based gait analysis approach was used. Two body-fixed sensors were positioned at the dorsal side of the pelvis and on the upper thorax. Peak-to-peak frontal plane range of motion (ROM) and spatiotemporal parameters (walking speed, step length and cadence) of persons with a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp. Participants were instructed to walk at a self-selected low, preferred and high speed along a hospital corridor. Generalized estimating equations (GEE) analyses were used to assess group differences between persons with a Duchenne limp, without a Duchenne limp and healthy subjects.
Persons with a Duchenne limp showed a significantly larger thoracic ROM during walking compared to healthy subjects and to persons without a Duchenne limp. In both groups of persons with hip osteoarthritis, pelvic ROM was lower than in healthy subjects. This difference however only reached significance in persons without a Duchenne limp. The ratio of thoracic ROM relative to pelvic ROM revealed distinct differences in trunk movement patterns. Persons with hip osteoarthritis walked at a significantly lower speed compared to healthy subjects. No differences in step length and cadence were found between patients and healthy subjects, after correction for differences in walking speed.
Distinctive patterns of frontal plane angular trunk movements during gait could be objectively quantified in healthy subjects and in persons with hip osteoarthritis using a body-fixed-sensor based gait analysis approach. Therefore, frontal plane angular trunk movements should be included in clinical gait assessments of persons with hip osteoarthritis.
Several studies have shown that severe spinal deformity and early arthrodesis can adversely affect the development of the spine and thorax by changing their shape and reducing their normal function. This article analyzes the consequences of posterior fusion on the growth of spine, thorax and neural elements in New Zealand white rabbits and compares with similar human data.
Materials and Methods:
The first section of the article analyzes the consequences of T1-T6 dorsal arthrodesis on the growth of the spine, sternum, thorax volume and neural elements in 12 prepubertal female New Zealand white rabbits, through a study of CT scans and histology specimens. The second part, evaluates thoracic dimensions in 21 children with spinal arthrodesis for treatment of deformity performed prior to nine years of age.
Dorsal arthrodesis in prepubertal rabbits changes thoracic growth patterns. In operated rabbits thoracic depth grows more slowly than thoracic width. The sternum as well as length of thoracic vertebral bodies in the spinal segment T1-T6 show reduced growth. Children undergoing spinal arthrodesis before nine years of age were noted to have shortened height, short trunk and disproportionate body habitus at skeletal maturity. Observed spine height and chest dimension values were reduced compared to the expected norms. The ratio between chest width and chest depth was below normal values.
The first part of the study shows that thoracic dorsal arthrodesis in prepubertal New Zealand white rabbit influences thoracic, spine growth and affects the shape of pseudo unipolar neurons of the dorsal root ganglia. The second part demonstrates that children treated before nine years of age have significantly reduced spine height and thoracic dimensions. The thorax becomes elliptical as chest depth grows less than chest width. Both experimental and clinical findings contribute to explain reduced chest growth and subsequent thoracic growth disturbance in patients treated with early arthrodesis.
Dorsal arthrodesis; thorax and spine growth; dorsal root ganglia; prepubertal rabbits; skeletal maturity
Aging of the spine is characterized by facet joints arthritis, degenerative disc disease and atrophy of extensor muscles resulting in a progressive kyphosis. Recent studies confirmed that patients with lumbar degenerative disease were characterized by an anterior sagittal imbalance, a loss of lumbar lordosis and an increase of pelvis tilt. The aim of this paper was thus to describe the different compensatory mechanisms which are observed in the spine, pelvis and/or lower limbs areas for patients with severe degenerative spine.
We reviewed all the compensatory mechanisms of sagittal unbalance described in the literature.
According to the severity of the imbalance, we could identify three different stages: balanced, balanced with compensatory mechanisms and imbalanced. For the two last stages, the compensatory mechanisms permitted to limit consequences of lumbar kyphosis on the global sagittal alignment. Reduction of thoracic kyphosis, intervertebral hyperextension, retrolisthesis, pelvis backtilt, knee flessum and ankle extension were the main mechanisms described in the literature. The basic concept of these compensatory mechanisms was to extend adjacent segments of the kyphotic spine allowing for compensation of anterior translation of the axis of gravity.
To avoid underestimate the severity of the degenerative spine disorder, it thus seems important to recognize the different compensatory mechanisms from the upper part of the trunk to the lower limbs. We propose a three steps algorithm to analyse the balance status and determine the presence or not of these compensatory mechanisms: measurement of pelvis incidence, assessment of global sagittal alignment and analysis of compensatory mechanisms successively in the spine, pelvis and lower limbs areas.
Sagittal balance; Pelvis; Spinal alignment; Lumbar lordosis; Degenerative disc disease; Lumbar kyphosis
Walking is impaired in Pregnancy-related Pelvic girdle Pain (PPP). Walking velocity is reduced, and in postpartum PPP relative phase between horizontal pelvis and thorax rotations was found to be lower at higher velocities, and rotational amplitudes tended to be larger. While attempting to confirm these findings for PPP during pregnancy, we wanted to identify underlying mechanisms. We compared gait kinematics of 12 healthy pregnant women and 12 pregnant women with PPP, focusing on the amplitudes of transverse segmental rotations, the timing and relative phase of these rotations, and the amplitude of spinal rotations. In PPP during pregnancy walking velocity was lower than in controls, and negatively correlated with fear of movement. While patients’ rotational amplitudes were larger, with large inter-individual differences, spinal rotations did not differ between groups. In the patients, peak thorax rotation occurred earlier in the stride cycle at higher velocities, and relative phase was lower. The earlier results on postpartum PPP were confirmed for PPP during pregnancy. Spinal rotations remained unaffected, while at higher velocities the peak of thorax rotations occurred earlier in the stride cycle. The latter change may serve to avoid excessive spine rotations caused by the larger segmental rotations.
Pregnancy-related Pelvic girdle Pain; Gait kinematics; Transverse rotation; Trunk coordination; Relative phase
Brain metastases arise in 10%–40% of all cancer patients. Up to one third of the patients do not have previous cancer history. We report a case of a 67-years-old male patient who presented with confusion, tremor, and apraxia. A brain MRI revealed an isolated right temporal lobe lesion. A thorax-abdomen-pelvis CT scan showed no primary lesion. The patient underwent a craniotomy with gross-total resection. Histopathology revealed an intestinal-type adenocarcinoma. A colonoscopy found no primary lesion, but a PET-CT scan showed elevated FDG uptake in the appendiceal nodule. A right hemicolectomy was performed, and the specimen showed a moderately differentiated mucinous appendiceal adenocarcinoma. Whole brain radiotherapy was administrated. A subsequent thorax-abdomen CT scan revealed multiple lung and hepatic metastasis. Seven months later, the patient died of disease progression. In cases of undiagnosed primary lesions, patients present in better general condition, but overall survival does not change. Eventual identification of the primary tumor does not affect survival. PET/CT might be a helpful tool in detecting lesions of the appendiceal region. To the best of our knowledge, such a case was never reported in the literature, and an appendiceal malignancy should be suspected in patients with brain metastasis from an undiagnosed primary tumor.
The adoption by humans of an upright position resulted in broadening and verticalisation of the pelvis together with the appearance of characteristic spinal curves, has profoundly modified the structure of the muscles supporting the spine.
In order to characterise the sagittal balance of the pelvis, it is necessary to define parameters based on notable biomechanical forces involved in the transmission of constraints. The angle of incidence was constructed to enable reproducible analysis of the anatomical characteristics of the pelvis in the sagittal plane. The angle of incidence is the algebraic sum of two complementary angles: pelvic tilt (PT) and sacral slope (SS). Since the value of incidence is fixed for any given patient, the sum of pelvic tilt and sacral slope is a constant value: when one increases, the other necessarily decreases.
The position of the lumbar spine, attached to the sacral plateau, is thus affected by the pelvic tilt and by the sacral slope. Consequently, the pelvic parameters affect the entire underlying sagittal spinal profile.
Global spinal balance involves harmonisation of lumbar lordosis and thoracic kyphosis taking into account the pelvic parameters.
Sagittal balance; Incidence angle; Pelvic tilt; Sacral slope; Pelvic parameters
Progressive and/or painful adult spinal deformity in the thoracolumbar and lumbar spine is sometimes treated surgically by long posterior fusions from the thoracic spine down to the pelvis, especially where there is a major thoracic curve component. Recent advances in anterior spinal instrumentation and spinal surgery technique have demonstrated the improved corrective ability offered by anterior stabilization systems, and the added benefit of limiting the number of vertebral fusion levels required for control of the deformity. The “hybrid technique” is a novel use of anterior instrumentation that applies limited anterior instrumentation down to the low lumbar spine (rods and screws), and partially overlapping short-segment posterior instrumentation to the sacrum (pedicle screws and rods). These constructs avoid posterior thoracic instrumentation and fusions, and avoid extension of posterior instrumentation to the pelvis. In the first 10 patients treated using this technique, thoracolumbar and lumbar major curve correction has averaged 71 and 82% in the immediate postoperative period (n = 7), respectively, and 59 and 68% at 2-year follow-up, respectively. The technique is an appealing and attractive alternative for treatment of thoracolumbar and lumbar scoliosis in the adult population, and avoids the requirement for applying spinal fixation to the thoracic spine and the pelvis.
thoracolumbar; lumbar; spinal deformity; surgical technique
Femoroacetabular impingement may occur in patients with so-called acetabular retroversion, which is seen as the crossover sign on standard radiographs. We noticed when a crossover sign was present the ischial spine commonly projected into the pelvic cavity on an anteroposterior pelvic radiograph. To confirm this finding, we reviewed the anteroposterior pelvic radiographs of 1010 patients. Nonstandardized radiographs were excluded, leaving 149 radiographs (298 hips) for analysis. The crossover sign and the prominence of the ischial spine into the pelvis were recorded and measured. Interobserver and intraobserver variabilities were assessed. The presence of a prominent ischial spine projecting into the pelvis as diagnostic of acetabular retroversion had a sensitivity of 91% (95% confidence interval, 0.85%–0.95%), a specificity of 98% (0.94%–1.00%), a positive predictive value of 98% (0.94%–1.00%), and a negative predictive value of 92% (0.87%–0.96%). Greater prominence of the ischial spine was associated with a longer acetabular roof to crossover sign distance. The high correlation between the prominence of the ischial spine and the crossover sign shows retroversion is not just a periacetabular phenomenon. The affected inferior hemipelvis is retroverted entirely. Retroversion is not caused by a hypoplastic posterior wall or a prominence of the anterior wall only and this finding may influence management of acetabular disorders.
Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Bipedalism is a distinguishing feature of the human race and is characterised by a narrow base of support and an ergonomically optimal position thanks to the appearance of lumbar and cervical curves.
The pelvis, adapted to bipedalism, may be considered as the pelvic vertebra connecting the spine to the lower limbs. Laterally, the body’s line of gravity is situated very slightly behind the femoral heads laterally, and frontally it runs through the middle of the sacrum at a point equidistant from the two femoral heads.
Any abnormal change through kyphosis regarding the spinal curves results in compensation, first in the pelvis through rotation and then in the lower limbs via knee flexion. This mechanism maintains the line of gravity within the base of support but is not ergonomic. To analyse sagittal balance, we must thus define the parameters concerned and the relationships between them.
These parameters are as follows: for the pelvis: incidence angle, pelvis tilt, sacral slope; for the spine: point of inflexion, apex of lumbar lordosis, lumbar lordosis, spinal tilt at C7; for overall analysis: spino-sacral angle, which is an intrinsic parameter.
Sagittal balance; Gravity line; Spino-sacral angle; Incidence angle
Tuberculosis is the commonest of the infections world wide and it can affect almost any part of the body, most commonly the thorax. The spine is affected in 50 % of the cases of skeletal tuberculosis. A tuberculous infection of the spine causes a bony destruction and collapse of the vertebrae, with a gibbus deformity, skip lesions, an intervertebral disc involvement, an epidural abscess, a paravertebral abscess and oedema in the soft tissue planes. Magnetic Resonance Imaging (MRI) is the most valuable investigation in the patients with spinal tuberculosis, as it can clearly demonstrate all of the above findings.
In this study, the MRI scans of 70 known cases of tuberculosis of the spine, which were done in the Department of Radiodiagnosis, R.D.Gardi Medical College, Ujjain, India, were retrospectively analyzed, to determine the pattern of occurrence of various pathological lesions.
It was found in this study, that Pott’s spine was most commonly observed in the 21-50 years age group, with a male predominance. The dorsal and the lumbar vertebrae are commonly involved and multiple vertebrae were often affected, the L3 vertebra being the commonest. An intervertebral disc involvement and pre and paravertebral collections were commonly seen, with an epidural collection occurring in more than 75 % of the cases. Cord oedema was noted in 10% of the cases.
The MRI scan is highly sensitive in the detection of various pathological processes of Pott’s spine and the patterns of occurrence of these findings were analyzed in this study. Since the incidence and prevalence of tuberculosis are dependent on various epidemiologically sensitive parameters, this study can provide a benchmark, against which the results of studies which will be done in the future can be compared.
Tubercular spondylitis; Psoas abscess; Gibbus
The Anterior Pelvic Plane (APP), defined by the anterior superior iliac spines and the pubic tubercle, was commonly used as reference for positioning and postoperative evaluation of the orientation of the acetabular cup in total hip arthroplasty. APP was assumed to be vertical, but was not observed always so, mostly because of associated spinal diseases inducing perturbations in the harmony of the sagittal balance of the pelvi-spinal unit. Consequently a sagittal rotation of the pelvis occurs, and so a tilt of the APP which alters directly the orientation of the cup in upright position. An analysis of the APP tilt related to the sagittal balance of the spine was provided and its implication on the cup orientation. It appeared essential for an individual adjustment of the cup positioning to avoid a functional mal-position which can lead to an increased risk of dislocation and impingement.
Gastrointestinal stromal tumors (GISTs) are rare, but represent the most common mesenchymal neoplasms of the gastrointestinal tract. Tumor resection is the treatment of choice for localized disease. Tyrosine kinase inhibitors (imatinib, sunitinib) are the standard therapy for metastatic or unresectable GISTs. GISTs usually metastasize to the liver and peritoneum. Bone metastases are uncommon. We describe three cases of bone metastases in patients with advanced GISTs: two women (82 and 54 years of age), and one man (62 years of age). Bones metastases involved the spine, pelvis and ribs in one patient, multiple vertebral bodies and pelvis in one, and the spine and iliac wings in the third case. The lesions presented a lytic pattern in all cases. Two patients presented with multiple bone metastases at the time of initial diagnosis and one patient after seven years during the follow-up period. This report describes the diagnosis and treatment of the lesions and may help clinicians to manage bones metastases in GIST patients.
gastrointestinal stromal tumors; computerezed tomografy; scan; bone metastases; Imatinib.
There is a wide variation in the regional parameters used to describe the spine and sacro-pelvis in children and adolescents. There is a slight tendency for thoracic kyphosis and lumbar lordosis to increase with age. Pelvic incidence and pelvic tilt also tend to increase during growth, while sacral slope remains relatively stable. Strong knowledge of the close relationships between adjacent anatomical regions of the spine and sacro-pelvis is the key when evaluating and interpreting sagittal spino-pelvic alignment. The scheme of correlations between adjacent regional parameters needs to be preserved in order to maintain a balanced posture. The net resultant from these relationships between adjacent anatomical regions is best represented by parameters of sagittal global balance. C7 plumbline tends to move backwards from childhood to adulthood, where it stabilizes or slightly moves forward secondary to degenerative changes. C7 plumbline in front of both hip axis and center of the upper sacral endplate occurs in 29% of subjects aged 3–10 years, 12% of subjects aged between 10 and 18 years, and 14% of subjects aged 18 years or older. Therefore, although most normal subjects stand with a C7 plumbline behind the hip axis, a C7 plumbline in front of both hip axis and sacrum can be seen in normal individuals. However, progressive forward displacement of C7 plumbline should raise a suspicion for the risk of developing spinal pathology.
Morphology; Pelvis; Posture; Sagittal alignment; Sagittal balance; Spine
The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI).
Twenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI.
Intervention and Outcome
Patients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable.
The patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.
Urinary incontinence; Pelvic floor; Manipulation, Chiropractic; Kinesiology, applied
Renal cell carcinoma is the most common kidney tumor in adults and accounts for approximately 3% of adult malignancies. An increased incidence of second malignancies has been well documented in a number of different disorders, such as head and neck tumors, and hairy cell leukemia. In addition, treatment associated second malignancies (usually leukemias and lymphomas but also solid tumors) have been described in long term survivors of Hodgkin's lymphoma (HL), Non Hodgkin's lymphoma and in various pediatric tumors.
We present the case of a 66 year-old woman with abdominal pain and dyspnea. We performed a thorax CT scan that showed lymph nodes enlargement and subsequently by presence of abdominal pain was performed an abdominal and pelvis CT scan that showed a right kidney tumor of 4 × 5 cms besides of abdominal lymph nodes enlargement. A radical right nephrectomy was designed and Hodgkin's lymphoma was diagnosed in the abdominal lymph nodes while renal cell tumor exhibited a renal cell cancer. Patient received EVA protocol achieving complete response.
We described the first case reported in the medical literature of the coexistence between Hodgkin's lymphoma and renal cell cancer. Previous reports have shown the relationship of lymphoid neoplasms with solid tumors, but they have usually described secondary forms of cancer related to chemotherapy.
People who suffer from low back pain (LBP) exhibit an abnormal gait pattern, characterized by shorter stride length, greater step width, and an impaired thorax-pelvis coordination which may undermine functional walking. As a result, gait in LBP may require stronger cognitive regulation compared to pain free subjects thereby affecting the degree of automaticity of gait control. Conversely, because chronic pain has a strong attentional component, diverting attention away from the pain might facilitate a more efficient walking pattern.
Twelve individuals with LBP and fourteen controls participated. Subjects walked on a treadmill at comfortable speed, under varying conditions of attentional load: (a) no secondary task, (b) naming the colors of squares on a screen, (c) naming the colors of color words ("color Stroop task"), and (d) naming the colors of words depicting motor activities. Markers were attached to the thorax, pelvis and feet. Motion was recorded using a three-camera SIMI system with a sample frequency of 100 Hz. To examine the effects of health status and attention on gait, mean and variability of stride parameters were calculated. The coordination between thoracic and pelvic rotations was quantified through the mean and variability of the relative phase between those oscillations.
LBP sufferers had a lower walking speed, and consequently a smaller stride length and lower mean thorax-pelvis relative phase. Stride length variability was significantly lower in the LBP group but no significant effect of attention was observed. In both groups gait adaptations were found under performance of an attention demanding task, but significantly more so in individuals with LBP as indicated by an interaction effect on relative phase variability.
Gait in LBP sufferers was characterized by less variable upper body movements. The diminished flexibility in trunk coordination was aggravated under the influence of an attention demanding task. This provides further evidence that individuals with LBP tighten their gait control, and this suggests a stronger cognitive regulation of gait coordination in LBP. These changes in gait coordination reduce the capability to deal with unexpected perturbations, and are therefore maladaptive.
To investigate the feasibility and accuracy of dose calculation in cone beam CT (CBCT) data sets.
Kilovoltage CBCT images were acquired with the Elekta XVI system, CT studies generated with a conventional multi-slice CT scanner (Siemens Somatom Sensation Open) served as reference images. Material specific volumes of interest (VOI) were defined for commercial CT Phantoms (CATPhan® and Gammex RMI®) and CT values were evaluated in CT and CBCT images. For CBCT imaging, the influence of image acquisition parameters such as tube voltage, with or without filter (F1 or F0) and collimation on the CT values was investigated. CBCT images of 33 patients (pelvis n = 11, thorax n = 11, head n = 11) were compared with corresponding planning CT studies. Dose distributions for three different treatment plans were calculated in CT and CBCT images and differences were evaluated. Four different correction strategies to match CT values (HU) and density (D) in CBCT images were analysed: standard CT HU-D table without adjustment for CBCT; phantom based HU-D tables; patient group based HU-D tables (pelvis, thorax, head); and patient specific HU-D tables.
CT values in the CBCT images of the CATPhan® were highly variable depending on the image acquisition parameters: a mean difference of 564 HU ± 377 HU was calculated between CT values determined from the planning CT and CBCT images. Hence, two protocols were selected for CBCT imaging in the further part of the study and HU-D tables were always specific for these protocols (pelvis and thorax with M20F1 filter, 120 kV; head S10F0 no filter, 100 kV). For dose calculation in real patient CBCT images, the largest differences between CT and CBCT were observed for the standard CT HU-D table: differences were 8.0% ± 5.7%, 10.9% ± 6.8% and 14.5% ± 10.4% respectively for pelvis, thorax and head patients using clinical treatment plans. The use of patient and group based HU-D tables resulted in small dose differences between planning CT and CBCT: 0.9% ± 0.9%, 1.8% ± 1.6%, 1.5% ± 2.5% for pelvis, thorax and head patients, respectively. The application of the phantom based HU-D table was acceptable for the head patients but larger deviations were determined for the pelvis and thorax patient populations.
The generation of three HU-D tables specific for the anatomical regions pelvis, thorax and head and specific for the corresponding CBCT image acquisition parameters resulted in accurate dose calculation in CBCT images. Once these HU-D tables are created, direct dose calculation on CBCT datasets is possible without the need of a reference CT images for pixel value calibration.
In recent years improvements have been made in techniques for transplanting fascia into the muscles of the abdomen to take over the function of paralyzed muscles. The techniques are described in this presentation.
Since muscular coordination of pelvis and thorax plays an important part in control of the extremities, better methods of placing transplants across the abdomen to link these regions offer, coincidentally, the benefit of better use of muscles in the arms and legs.
If done early and skillfully, abdominal fascial transplants and allied transplants not only aid in restoring function but often prevent deformities.