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Background Spine conditions are common and the surgery is evolving even in developed economies. This study aims to review the changing trends and challenges of spine surgery, particularly from a low-income country. Methods This is a retrospective study of patients who were surgically treated for spine conditions in Enugu, Nigeria. Patient records from 2006 to 2016 were reviewed. Relevant clinical information was extracted from the operation theater logbooks and patient case files. Results A total of 463 spine surgical procedures were carried out on the same number of patients. The number of treated patients has been on the increase and shows a male predominance. Pediatric spine cases accounted for 1.5%, adult/middle aged patients accounted for 77.8%. Degenerative conditions, trauma, and neoplasms were the most frequent indications for operation, accounting for 52.3%, 30.5%, and 11.4%, respectively. The most commonly operated region was cervical and lumbar regions among male (49.3%) and female (51.8%) patients, respectively. Spine fixation was required in 137 patients (29.6%). A paradigm shift from trauma to degenerative conditions among patients was noted after 2010. Prior to 2009, spine wiring techniques were the most common spine stabilizing method, but from 2011 to 2013 anterior cervical discectomy and anterior cervical discectomy and fusion predominated, and thereafter pedicle screws predominated. Cost implications, lack of trained personnel, and lack of and basic equipment pose significant challenges to spine care. Conclusions The trend in spinal surgery has improved rapidly and consistently in Nigeria over the 10 years of the study and is related to increasing expertise, more available facilities, and implant availability.

Imaging of the craniocervical junction (CCJ) after trauma is crucial for injury detection and description. Of all the anatomic measurements of the CCJ, the normal value of atlanto-occipital interval (AOI) is not yet well established in adults. The aim of our study is to determine the normal values of the AOI in Nigerians aged between 21 and 60 years using multidetector computed tomography (MDCT) scan and to determine racial, age, and sex differences.This was a prospective observational study done at Memfys Hospital for Neurosurgery, Enugu, Nigeria, between May 2016 and April 2017. There were 240 subjects (120 men and 120 women) divided into the following age groups: 21-30, 31-40, 41-50, and 51-60 years. Non-Nigerians and those with preexisting CCJ abnormalities were excluded. Normal values were those within the 95% confidence interval. Results were analyzed for possible sex and age variations and compared with the available literature for racial differences. Ethical approval was obtained for this study.The measured normal computed tomography value of the AOI in adult Nigerians was 1.181 ± 0.018 mm. The values in the age groups of 21-30, 31-40, 41-50, and 51-60 years were 1.279 ± 0.038, 1.164 ± 0.033, 1.151 ± 0.029, and 1.133 ± 0.033 mm, respectively (P0.05). The average normal values in men and women were 1.188 ± 0.025 and 1.174 ± 0.026 mm, respectively. The interobserver reliability test using the Cronbach α was 0.938.AOI values in this study were higher than previous MDCT-based values in non-African populations. The AOI decreased linearly with age and did not show any sex difference.

Background The evolution of neurosurgery in our center comprises 2 active phases separated by a decade-long latent phase. This study evaluates our experience in the renaissance phase using 1025 cases. We identify paradigms that predict progress under existing practice conditions. Methods A prospective observational study was undertaken of all freshly operated patients from 2009 to 2016. Ethical approval was obtained from the hospital institutional review board. Data of enrolled patients were acquired and analyzed using SPSS software for Windows version 21. Inferences were evaluated using a 95% level of significance. Major and intermediate cases were included, whereas bedside cases as well as patients operated on elsewhere were excluded. Results Of 5132 patients treated, 3033 had surgical lesions, 1129 (33.2 ± 2.7% confidence limit [CL]) were operated on, and 1025 satisfied the study criteria. The unmet surgical load (66.1%) was significant (χ2 = 10.9; degree of freedom = 1; P = 0.001). The most common diseases treated were neurotrauma in 438 patients, congenital malformations in 268, and tumors in 170. The mean annual operative rate was 125 ± 5.7 patients (95% CL). Cases showed significant variability using 1-way analysis of variance (F = 13.77; P = 0.03). Residency training was a positive influence on surgeons' operative rate (χ2 = 7.59; P = 0.02). The mean complication rate was 10.3% ± 2.9%, and the mortality was 5.5% ± 1.7%. Conclusions We found a large unmet neurosurgical load. To resolve this situation, we recommend an increase in the number of training programs for neurosurgery residency. As neurosurgery units evolve, their progress may be evaluated using the NESCAPE (Neurosurgery Care Phase Evolution) paradigm.

From conventional radiograph to magnetic resonance urography, imaging of urinary system has evolved with variety of investigations over the past several decades with each of them having advantages and limitations of their own. In the current era, computed tomography (CT) has emerged as a preferred investigations for evaluation of the urinary tract. There are various techniques involved in performing CT urography (CTU) with triple bolus technique (TB-CTU) currently drawing a special attention because of its low radiation exposure. This article aims to discuss the current techniques, indications, and clinical applications of CTU with illustrations.

Background Leisure sports activities are assumed to be safe. It is however possible that participation in contact sports as leisure activity may also affect the space available for the cervical cord (SAC). The objective of this study is to compare the SAC of asymptomatic young adults involved in active leisure contact sports with matched controls that do not participate in contact sports. Methods This magnetic resonance imaging–based prospective, cross-sectional study involved 204 randomly selected asymptomatic adults, 21–50 years of age. The study included 2 groups: group A (participants in active leisure contact sports) and group B (participants who did not participate in any form of contact sport). The SAC was calculated by subtracting disk-level midsagittal spinal canal dimension from the corresponding level spinal cord dimension. Results The SAC at C3-4 was 4.5 ± 1.1 mm (group A) and 4.9 ± 1.4 mm (group B) ( P = 0.025), at C4-5 was 4.3 ± 1.1 mm (group A) and 4.5 ± 1.2 mm (group B), at C5-6 was 4.6 ± 1.1 mm (group A) and 4.5 ± 1.4 mm (group B), at C6-7 was 5.2 ± 1.3 mm (group A) and 4.9 ± 1.2 mm (group B), at C7-T1 was 5.6 ± 1.3 mm (group A) and 5.6 ± 1.5 mm (group B) ( P = 0.004). In men, the SAC at C3-4 was 4.39 ± 0.28 mm (group A) and 4.90 ± 0.30 mm (group B) ( P = 0.036) and at C4-5 was 4.16 ± 0.27 mm (group A) and 4.56 ± 0.35 mm (group B). Three-way multivariate analysis of variance revealed significant effect of contact sports ( P = 0.005), sex ( P = 0.001), and age ( P = 0.0001) on the SAC. Combined effect of contact sports participation and age also have significant effects on the SAC ( P = 0.035). Conclusions Participation in leisure contact sports has a small but overall negative effect on the SAC, especially at the upper subaxial cervical spine levels. This effect is most marked after the age of 40 years. Overall, there was no sex difference observed.

The clinical diagnosis of musculoskeletal infections can be challenging due to non-specific signs and symptoms on presentation. These infections include infectious myositis, necrotising fasciitis, septic arthritis, septic bursitis, suppurative tenosynovitis, osteomyelitis, spondylodiscitis and periprosthetic infections. Diagnostic imaging is routinely employed as part of the investigative pathway to characterise the underlying infectious disease pattern, allowing expedited and customised patient management plans to optimise outcomes. This article provides an update on the various imaging modalities comprising of radiography, computed tomography, ultrasonography, magnetic resonance imaging and radionuclide procedures, and incorporates representative images of key findings in the different forms of musculoskeletal infections.

Peripheral nerve sheath tumours (PNST) may be benign or malignant. Benign PNSTs include neurofibroma and schwannoma. Neurogenic tumours share certain characteristic imaging features, suggested by a fusiform-shaped mass with tapered ends, the “split-fat” sign, atrophy of the muscles supplied by the involved nerve, the “fascicular sign,” and the “target sign”; these imaging features are best demonstrated on magnetic resonance imaging. This pictorial essay emphasizes the characteristic signs and distinguishing features of PNSTs on imaging.

Osteoporosis is a serious public health problem. The incidence of osteoporotic fractures increases with age. As life expectancy increases, social costs associated with osteoporotic fractures will multiply exponentially. The early diagnosis of osteoporosis, thanks to evermore precise devices, becomes, therefore, fundamental to prevent complications of disease and unnecessary suffering.

Musculoskeletal complaints are common in the elderly population. The main concerns in geriatric orthopedics are the increased incidence of trauma, degeneration, and malignancy, commonly compounded by comorbidities and the effects of ageing. Imaging of common and important diseases of the axial and peripheral skeleton in the elderly is reviewed in this article.

Percutaneous vertebroplasty is a safe, inexpensive, and effective interventional vertebral augmentation technique that provides pain relief and stabilization in carefully selected patients with severe back pain due to vertebral compression. Complications from percutaneous vertebroplasty can be devastating, but are rare and avoidable with application of a meticulous technique. Percutaneous vertebroplasty has a role in the management pathway of patients presenting with painful vertebral compression fractures. Kyphoplasty uses a balloon tamp with the aim of restoring vertebral body height, improving kyphotic deformity, and creating a cavity into which bone cement is injected. Kyphoplasty is as effective and safe as vertebroplasty in treatment of painful vertebral compression fractures. Skyphoplasty, a modification of kyphoplasty, is a promising new technique.

The development of OPIDN and the efficacy of experimental intervention using the calcium-channel blocker verapamil were used as a model to test the serial time-measurements of serum autoantibodies against neuronal cytoskeletal proteins [e.g., neurofilament triplet (NF)] and glial proteins [myelin-basic protein (MBP) and glial fibrillary-acidic protein (GFAP)] as biomarkers of neurotoxicity and its amelioration. Ten White Leghorn hens (>7 months, 1.2-1.8 kg) were administered phenyl-saligenin phosphate (PSP; 2.5 mg/kg; im), a dose reported to induce a 70% decrease in neurotoxic esterase (NTE) activity. Five of the hens were administered verapamil (7 mg/kg; im) for 4 days starting one day before PSP administration. Serum was isolated from blood collected by serial brachial venepuncture before PSP (day 0) administration and on days 3, 7 and 21 after PSP administration, each hen acting as its own control. Serum antibodies (IgG) to NF-L, NF-M, NF-H, MBP, and GFAP were assayed using an ELISA. There were no detectable levels of antibodies on days 0 and 3. IgG against all neural proteins were detected on days 7 and 21, with titer levels being significantly (p< or =0.05) higher in sera of hens receiving PSP only. Anti-NF-L titers were highest compared to those against NF-M, NF-H or MBP at 21 days. Titers of anti-NF-L and anti-MBP significantly (p< or =0.01) correlated with clinical scores at days 7 and 21. Detection of anti-NF and anti-MBP antibodies confirms the neuroaxonal degeneration accompanied by myelin loss reported in this model of OPIDN and the amelioration of neuropathy using verapamil. The detection of anti-GFAP antibodies suggests CNS involvement in OPIDN, since astrocytes are only found therein. This study demonstrates that detection of neuroantibodies can be used as biomarkers of neuropathy development and to monitor the amelioration resulting from therapeutic intervention. Together with biomarkers of exposure neuroantibodies can be used to monitor neuropathogenesis due to environmental or occupational exposures.

A 65-year-old Chinese woman presented with a painful and swollen right knee since 3 weeks. Despite treatment with analgesics, there was progression of pain and swelling. The radiographs showed bony destruction with associated soft tissue swelling, suggestive of septic arthritis. Magnetic resonance imaging revealed a large knee joint effusion and pockets of abscesses in the surrounding muscles and subcutaneous tissue. There was associated osteomyelitis in the femoral condyle and upper tibia. The culture of pus revealed Burkhoderia pseudomallei . The patient improved after 9 months of treatment by antibiotics and repeated debridement. Septic arthritis of the knee joint caused by Melioidosis is a rare entity that requires a prompt diagnosis. Clinically, it may mimic infective and non-infective arthritis. Lack of awareness of this condition may lead to patient morbidity and even mortality.

Aim : To illustrate the imaging features of malignant germ cell tumours complicating undescended testes, emphasizing the importance of recognizing this condition and providing a correct diagnosis to facilitate appropriate management. Methods : The clinical presentation, ultrasonography (US) and computed tomography (CT) features of eight consecutive patients with malignant germ cell tumours of undescended testes were reviewed. Results : CT performed in seven patients showed well-circumscribed soft-tissue masses with inhomogeneous enhancement in all cases. US in four patients showed circumscribed masses with inhomogeneous echogenicity. On pathological examination, there were two cases of embryonal carcinoma and six cases of seminoma. All tumours showed necrosis that correlated to inhomogeneous areas on imaging. Conclusion : The radiologist has an important role as he may be the first physician to suggest the diagnosis.

Background/Purpose: Scar formation after scald injury in children is managed commonly by application of pressure garment. The duration of the treatment depends on clinical assessment. The objective of the study was to evaluate the efficacy of the pressure garment therapy and to correlate the clinical assessment scar thickness with ultrasound measurement. Methods: Prospective study of children with hypertrophic scars receiving pressure garment therapy was carried out between 1993 and 1998. The scars were mapped with paper cutting. Representative scar sites were scored clinically according to Vancouver General Hospital Burn Assessment Scale (pigmentation, vascularity, pliability, height, pain, itchiness). Blind to the clinical results, 2 radiologists measured the scar thickness of the same sites with ultrasonography (5 to 10 MHz transducer, General Electric LOGIQ 500). The correlation between the clinical scores and ultrasound measurement of scar thickness were analysed using analysis of variance (ANOVA). Results: The median age of 58 children with scald injury (M:F = 36:22) was 2.8 years (0.5 to 15.8 years). The mean percentage of scald was 8.8% (24% had scald area >10%). In addition, there were 5 children with burn from naked flame and 9 children with keloid secondary to surgical incisions. With pressure garment therapy, the scar thickness reached a plateau 1½ years after the injury and began to decline gradually thereafter. The clinical estimation of scar thickness correlated well with the ultrasound measurement (ANOVA, P =.003, Adjusted R square=0.99). The accuracy rate of clinical thickness estimation was 67%. Overestimation and underestimation accounted for 15% and 18%, respectively. There also was good correlation between total clinical score and the ultrasound measurement (ANOVA, P Conclusions: In children with scald injury, the pressure garment needs to be continued for a minimum of 1 year. Ultrasound measurement correlates well with overall score of the Vancouver General Hospital Burn Assessment Scale but not individual components of the scoring system except wound height. J Pediatr Surg 36:466-469. Copyright © 2001 by W.B. Saunders Company.

The radiographs of 52 fresh cadaveric wrists were reviewed to assess their reliability in predicting the presence or absence of degenerative changes at the radiocarpal, midcarpal, and carpometacarpal joints. Direct comparison with anatomic dissection showed that except for the radioscaphoid articulation, there were no other sites with significant correlation between the radiographic and anatomic findings. We conclude that plain radiographs are not totally reliable for assessing changes of degenerative joint disease in the wrist.

Objectives. To assess the efficacy of a day case diagnostic service employing ultrasonography and flexible cystoscopy in the evaluation of patients presenting with painless gross hematuria. Methods. From July 1994 to June 1997 a prospective study was conducted for 312 consecutive patients presenting with painless gross hematuria. They were evaluated in a day case diagnostic service setting, where ultrasonography and flexible cystoscopy were performed together with other laboratory investigations. Intravenous urography was subsequently performed for possible additional diagnostic information. Results. Eighty-one urinary malignancies were detected in 78 patients; 51 were carcinoma of the bladder, and the next most common was renal cell carcinoma (n = 15). Definitive diagnoses were made in 68 patients and an abnormality was noted in 9 other patients after the day case workup. The day case diagnostic workup has led to highly selective use of computed tomography scans with high diagnostic yield; intravenous urography only added important diagnostic information, not available from the earlier workup, in 9 patients. Conclusions. Day case diagnostic service is a feasible arrangement. By combining ultrasonography and flexible cystoscopy, most carcinomas were diagnosed and abnormalities detected. Such a service enhances rapid completion of diagnostic workup, and operations for surgical conditions can be scheduled more promptly.

Arteriovenous shunting has been reported in hepatocellular carcinoma (HCC) and is a recognized contraindication to treatment by transcatheter arterial chemoembolization. This study aims to determine the prevalence of arteriovenous shunting in patients presenting with HCC and the development of shunts in those with inoperable HCC being treated with repeated chemoembolization. In a group of 292 Chinese patients (251 men, 41 women; mean age 54.7 years) presenting with HCC, hepatic angiograms demonstrated arteriovenous shunting in 91 cases (31.2%); shunting into the portal vein was observed in 84 (28.8%) and shunting into the hepatic vein in seven (2.4%). The hepatic angiograms of a separate group of 171 Chinese patients (144 men, 27 women: mean age 55.4 years) undergoing chemoembolization for inoperable HCC were analysed. Arteriovenous shunting developed during treatment in 20 patients (11.7%). Of these 20 patients, one had shunting into the hepatic vein while 19 (11.1%) had arterioportal shunting. Arteriovenous shunting occurred through the tumour or portal vein tumour thrombus in 13 patients, and occurred at sites remote from the tumour in the other seven patients. Shunting disappeared on repeat angiograms in three patients. Various postulated mechanisms responsible for arteriovenous shunting in HCC are reviewed. The recognition of development of arteriovenous shunting during chemoembolization of HCC is important as it has a direct bearing on patient management and prognosis.

Magnetic resonance imaging (MRI) is the imaging method of choice for evaluating the presence and extent of soft tissue masses. It is particularly useful for assessing masses in the wrist and hand, where benign lesions predominate. A specific diagnosis may be made, or strongly suspected, from the characteristic MRI features found in certain conditions like ganglion, haemangioma, arteriovenous malformation, giant cell tumour of the tendon sheath and lipoma.

Clinical and radiological features of 22 Chinese patients with sacral insufficiency fractures were reviewed. Twenty-one were postmenopausal women. Other risk factors were external pelvic radiotherapy (eight) and total hip replacement (two). Severe low back pain was the most common presenting complaint. Fractures initially were demonstrated by bone scintigraphy in 21 and computed tomography (CT) in seven patients. Concomitant parasymphyseal and pubic rami fractures were detected in 17 and 10 patients, respectively. Follow-up assessment by CT and bone scintigraphy in five patients showed various stages of fracture healing. Recognition of the radiological patterns of this entity is emphasized.

The association between radiotherapy and insufficiency fractures of the pelvis has not been well documented. Fractures were detected over a 2-year period in eight postmenopausal women who had previously undergone irradiation for gynaecological malignancies. Six of these patients also had local soft tissue complications, such as rectal bleeding and haematuria, in addition to severe low back, buttock or groin pain, caused by the fractures. Plain radio-graphs were unhelpful in the detection of sacral insufficiency fractures, but showed the pubic fractures in five patients. Diagnoses of insufficiency fractures were made on bone scintigraphic demonstration of the typical ‘H' shaped sacral pattern, or the combination of the partial ‘H' pattern together with pubic uptake. Computed tomography was useful for confirmation of insufficiency fractures in doubtful cases. Recognition of insufficiency fractures helps to avoid the pitfalls of misdiagnosing tumour recurrence or bony metastases.

Four Chinese patients with extensive smooth muscle tumors of the inferior vena cava (IVC) and right heart are described. Two patients had primary IVC leiomyosarcomas and one had both IVC and cardiac metastases from uterine leiomyosarcoma. The remaining patient had extra-uterine intravenous leiomyomatosis, with extensive tumor calcification. Clinical presentation was variable, consisting of the Budd-Chiari syndrome, a new heart murmur, and signs of cerebral embolism. All the lesions were defined radiologically prior to surgical resection of cardiac tumors.

An acute presentation of the superior mesenteric artery syndrome was diagnosed in a 13-year-old Chinese boy in whom no predisposing cause was found at surgery. Duodenogram combined with dynamic computed tomography, including 2-dimensional multiplanar reconstructions, was useful in confirming the diagnosis prior to definitive surgery.

Development of typical pseudoarthrosis from an acute fracture in the spine of a patient with ankylosing spondylitis is documented by serial radiographs. The magnetic resonance imaging appearances of pseudoarthrosis are correlated with histological findings of the surgical specimen.

The H-shaped sacral pattern on bone scintigraphy, considered characteristic for the diagnosis of sacral insufficiency fractures, was demonstrated in a 77-year-old woman with recurrent metastatic carcinoma of the breast. In addition to confirming the presence of sacral and pubic insufficiency fractures, computed tomography showed a malignant lesion in the right sacral ala. We suggest that the scintigraphic 'H' or 'butterfly' sign is not pathognomonic for sacral insufficiency fractures as it may mask coexisting malignancy.

The importance of punch length uniformity to the control of tablet weight variation was demonstrated in a rotary tablet press. An assessment of the weight variation of single-station compression on the multiple-station tablet press was obtained by means of a special isolation technique involving a force-actuated weight control device. Analysis of the relation between punch length and compression force pointed to the uncertainty of the relationship between tablet weight and compression force when variations of upper and lower punch lengths are considered. Control of tablet weight based on compression force signal suffers from this uncertainty, as demonstrated by experimental data.

In this study, we conduct a laboratory experiment to evaluate three alternative mechanisms for pricing transfers between a buyer and a seller. The three mechanisms are: (1) a direct negotiation mechanism with which either party suggests terms of trade that the other can accept or reject; (2) a traditional mechanism where the transfer price and quantity are determined by the intersection of the reported demand and supply schedules of the buyer and seller, respectively; and (3) the Ronen-McKinney mechanism which computes the transfer quantity in the same way as the traditional mechanism, but is designed to give different transfer prices to the buyer and seller in order to induce them to truthfully report their respective schedules. For all periods of the experiment, the direct negotiation mechanism is the least efficient of the three due to the high frequency of bargaining impasses. The efficiency of the traditional mechanism and the efficiency of the Ronen-McKinney mechanism are indistinguishable from one another. However, in the last four periods of the experiment where the data exhibit less volatility, the efficiencies of all three mechanisms are indistinguishable from each other. When truthful reporting is considered, the Ronen-McKinney mechanism had the least amount of misreporting followed by the traditional mechanism and then the direct negotiation mechanism.

Using the data from sealed offer laboratory markets, we compare the price and quality choices of student subjects with those of businessmen subjects. The businessmen subjects were public accounting firm partners and corporate financial officers. This is of interest since the financial officer-auditor relationship is one particular application of the elementary principal-agent model which the laboratory environment was designed to test. Using several different performance measures we are unable to reject the null hypothesis that the average performance of the two subject pools were the same. However, the market using businessmen subjects generally exhibited greater variance than the market using students.

This paper examines the extent to which practicing CPAs may employ two heuristics, representativeness and protectiveness, which lead to systematic errors in the judgement evaluation of sample outcomes. The results indicate that both heuristics are used, but to a lesser extent than suggested by previous research. Implications of the results for audit firm policy are discussed.