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Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Fibromyalgia is a complex disease process that is as prevalent as it is poorly understood. Research into the pathophysiology is ongoing, and findings will likely assist in identifying new therapeutic options to augment those in existence today that are still insufficient for the care of a large population of patients. Recent evidence describes the use of cannabinoids in the treatment of fibromyalgia. This study provides a systematic, thorough review of the evidence alongside a review of the seminal data regarding the pathophysiology, diagnosis, and current treatment options. Fibromyalgia is characterized by widespread chronic pain, fatigue, and depressive episodes without an organic diagnosis, which may be prevalent in up to 10% of the population and carries a significant cost in healthcare utilization, morbidity, a reduced quality of life, and productivity. It is frequently associated with psychiatric comorbidities. The diagnosis is clinical and usually prolonged, and diagnostic criteria continue to evolve. Some therapies have been previously described, including neuropathic medications, milnacipran, and antidepressants. Despite some level of efficacy, only physical exercise has strong evidence to support it. Cannabis has been used historically to treat different pain conditions since ancient times. Recent advances allowed for the isolation of the active substances in cannabis and the production of cannabinoid products that are nearly devoid of psychoactive influence and provide pain relief and alleviation of other symptoms. Many of these, as well as cannabis itself, are approved for use in chronic pain conditions. Evidence supporting cannabis in chronic pain conditions is plentiful; however, in fibromyalgia, they are mostly limited. Only a handful of randomized trials exists, and their objectivity has been questioned. However, many retrospective trials and patient surveys suggest the significant alleviation of pain, improvement in sleep, and abatement of associated symptoms. Evidence supporting the use of cannabis in chronic pain and specifically in fibromyalgia is being gathered as the use of cannabis increases with current global trends. While the current evidence is still limited, emerging data do suggest a positive effect of cannabis in fibromyalgia. Cannabis use is not without risks, including psychiatric, cognitive, and developmental as well as the risks of addiction. As such, clinical judgment is warranted to weigh these risks and prescribe to patients who are more likely to benefit from this treatment. Further research is required to define appropriate patient selection and treatment regimens.

The objectives of this review are to describe the acquired and hereditary causes of methemoglobinemia, to recommend the most sensitive diagnostic tests, and to enable critical care clinicians to rapidly detect and treat methemoglobinemia. To meet these objectives, Internet search engines were queried with the keywords to select articles for review that included case reports, case series, observational, longitudinal, and surveillance studies. The most common causes of methemoglobinemia include oxidizing reactions to cocaine-derived anesthetics, such as benzocaine and lidocaine, to antibiotics, such as dapsone and other sulfonamides, and to gases, such as nitric oxide. Additionally, CO-oximetry is superior to standard pulse oximetry in detecting methemoglobinemia. Finally, effective treatments for methemoglobinemia include intravenous administration of methylene blue, ascorbic acid, and riboflavin. In this manuscript we will discuss methemoglobinemia, how it occurs, and how to treat it.

Regional anesthesia is an important aspect of the overall anesthetic plan for patients. It has the potential to offer superior benefits compared to opioid-based treatment and is an important component of Enhanced Recovery after Surgery (ERAS) protocols. The use of the pectoral type I (PECS I) and pectoral type II blocks (PECS II) has been shown to reduce postoperative pain and opioid consumption in patients undergoing complete mastectomy and breast surgery. We describe the use of dexamethasone and dexmedetomidine to prolong the analgesic effects of these regional blocks in a patient undergoing total mastectomy with lymph node dissection.

Dexmedetomidine, a selective and potent α2-adrenoceptor agonist, is used for its anxiolytic, sedative, and analgesic properties. Dexamethasone is a high-potency, long-acting glucocorticoid that has been shown to provide analgesic and anti-inflammatory effects. At present, little has been published with regard to the effectiveness of these drugs as dual agents with local anesthetics for analgesia. In this report, a case of a 50-year-old man who underwent a cervical spine orthopedic procedure is described, in which an intraoperative injection of ropivacaine was administered with the adjuvants dexmedetomidine and dexamethasone, providing extended postoperative pain relief. In summary, we present a patient who had an injection of ropivacaine with dexmedetomidine and dexamethasone into the erector spinae muscles in the cervical region, which provided improvement in postoperative pain and reduced opioid consumption for five days post-surgery, demonstrating additive and/or synergistic effects beyond the normal local anesthetic duration.

Total knee arthroplasty (TKA) is among the most commonly performed orthopedic procedures. Controlling the pain of this patient population is essential in improving outcomes such as opioid consumption, hospital length of stay, overall function, and rehabilitation participation following their procedure. Local anesthetic infiltration of the interspace between the popliteal artery and capsule of the posterior knee, known as the IPACK block, combined with an adductor canal block (ACB) can be used to reduce pain in the challenging area of the posterior knee after knee surgery without compromising motor function of the quadriceps muscles. One limiting factor to this combination of techniques is the duration of analgesia provided. This case series demonstrates the combination of dexmedetomidine and dexamethasone (Dex-Dex) as local anesthetic adjuvants to significantly prolong the analgesic duration of ACB (in addition to IPACK block) in three patients undergoing TKA. Preoperative ACB and IPACK blocks were performed for postoperative analgesia in three TKA patients. The anesthetic mixture was 10 cc 0.2% ropivacaine combined with 25 mcg of dexmedetomidine and 5-mg preservative-free dexamethasone for the ACB, and 0.2% ropivacaine combined with 5-mg preservative-free dexamethasone was utilized for the IPACK block. Two of the patients reported experiencing four days of analgesia and one patient reported five days of analgesia following the ACB + IPACK block. Two of the patients required no opioid analgesics postoperatively. An ACB utilizing 0.75% ropivacaine has been demonstrated to provide approximately 10.8 hours of analgesia. Our series demonstrates a significantly prolonged duration of analgesia from this injectate combination. Few studies have utilized the Dex-Dex combination. The combination, however, was previously proven to safely increase the analgesic duration of a caudal block prior to hypospadias surgeries in pediatrics. More studies are needed to understand a potential synergistic effect of Dex-Dex, which could have a substantial impact on postoperative analgesia for TKA patients.

Acute pancreatitis is the most common gastrointestinal pathology that warrants hospital admission, with an estimated incidence of 13-45/100,000 annually in the US. The overall mortality is low but is significantly increased in 15-25% of patients that develop severe disease, likely secondary to an increase in inflammation and an exaggerated response, sometimes referred to as a cytokine storm. Management is largely supportive, and no specific cure exists to hasten recovery. Icosapent Ethyl (IPE, Vascepa®) is an omega-3 fatty acid derivative that is indicated for the treatment of hypertriglyceridemia and has been shown to improve mortality from cardiovascular causes, likely through an anti-inflammatory mechanism. We report here a case of very severe, abrupt acute alcoholic pancreatitis in a 31-year-old male, requiring intensive care unit admission, ventilation, and support with multiple vasoactive medications. Shortly after the initiation of IPE, the patient started to improve and ultimately made a complete recovery. His initially greatly elevated inflammatory markers downtrended quickly under IPE treatment and he followed with a remarkable clinical recovery. Several previous studies, such as the Patients With Persistent High Triglyceride Levels (≥ 200 mg/dL and < 500 mg/dL) Despite Statin Therapy (ANCHOR; NCT01047501) and the Multi-Center, PlAcebo-Controlled, Randomized, Double-BlINd, 12-week study with an open-label Extension (MARINE; NCT01047683), provided evidence of the anti-inflammatory activity of IPE. In our case, we provide the first evidence to support its use as a direct anti-inflammatory in severe disease. With the absence of direct therapy and the significant mortality from severe acute pancreatitis, IPE can be a breakthrough therapy. Its treatment is not limited to pancreatitis only, and it may also be beneficial in other cases of severe inflammation. Though anecdotal, this case provides evidence to support further study of IPE in states of exaggerated inflammation.

Regional anesthesia has found many advocates as enhanced recovery after surgery continues to become a more popular option for procedures such as total hip arthroplasty. Among the many benefits is the better pain control with a reduction or complete elimination of the need for opioids for perioperative pain management. With aims to improve the multi-modal approach to pain management, we present a case demonstrating further improvements in the regional anesthetic technique with the addition of a dexamethasone and dexmedetomidine adjuvant to the local anesthetic injectate. Our case is that of a 65-year-old woman with a history of hypertension, hyperlipidemia, and right hip osteoarthritis undergoing a right total hip arthroplasty who received a preoperative ultrasound-guided fascia iliaca block with the adjuvants dexamethasone and dexmedetomidine added to the injectate. The surgery was uneventful. She did not require any postoperative opioid or non-opioid analgesics, denying any pain for the first three postoperative days.

Pectoral type I and II (Pecs I and II) blocks are regional anesthesia methods that have shown to decrease postoperative analgesia after breast surgery. Typically, these blocks consist only of a local anesthetic. We performed preoperative Pecs I and II blocks in a female patient undergoing surgical excision and biopsy of a breast mass. The anesthetic consisted of ropivacaine, dexmedetomidine, and dexamethasone (Dex-Dex). The patient experienced an extended postoperative pain relief period. She did not require any opiates postoperatively. Adding dexmedetomidine and dexamethasone to a local anesthetic for peripheral nerve blocks seems to have a synergistic effect and can extend the duration of pain relief. This combination has the potential to decrease postoperative opiate requirements for analgesia. Further studies need to be conducted to further determine the safety and efficacy of the Dex-Dex block.

COVID-19 is a fatal, universal pandemic caused by the SARS-CoV-2 virus that has directly caused at least 95,235 deaths in the US by May 2020. It has a poor prognosis with a mortality rate as high as 21% in the general population at the height of the pandemic, a rate that is much higher in elderly patients, as well as those requiring intensive care unit (ICU) care. The role of inflammation in symptomatic COVID-19 is being studied, and it is hypothesized that hyper-inflammation is a causative factor in severe COVID-19 disease. Treatment options are limited and mostly rely on supportive care. Icosapent ethyl (IPE) is an Omega-3 fatty acid derivative that has been shown to significantly reduce cardiovascular mortality and is used as an adjunct to statin therapy. Though it has been shown to act as an anti-inflammatory, it is not currently indicated for that purpose. Here, we describe, for the first time, the successful treatment of a COVID-19 patient with IPE.

Regional anesthetic techniques have become a vital part of the perioperative pain control process. The opioid crisis remains a major obstacle in the medical field today and many practitioners have looked upon regional nerve blocks to decrease opioid usage. The erector spinae plane block (ESPB) has gained prominence as a viable option for perioperative pain control for numerous procedures. Spinal surgery, although mostly utilized to relieve back pain, can be extremely painful for the patient perioperatively. To mitigate pain, many practitioners have turned to oral analgesics as regional techniques have not been typically employed. Anterior cervical discectomy and fusion (ACDF) surgeries in particular have been implicated as exquisitely painful and may predispose patients to sustained opioid use postoperatively. Many of these patients are on chronic opioid therapy and they have developed the syndrome of opioid abuse hyperalgesia; therefore, decreasing the need for opioids postoperatively is of utmost importance. We present the case of a successful ESPB performed prior to emergence for a patient undergoing ACDF to limit opioid consumption. Informed consent was provided by the patient for this case report.

Objective: Two patient case reports are presented describing the use of cannabidiol (CBD) for the symptomatic relief of a lumbar compression fracture and in the mitigation of thoracic discomfort and dysesthesia secondary to a surgically resected meningioma.Discussion: CBD appears to have antisnociceptive and anti-inflammatory effects on opioid-naive patients with neuropathic and radicular pain. Of note, the patients in this case series used the same CBD cream: Baskin Essentials Body Wellness Cream (400 mg CBD per two oz.)Conclusion: Hemp-derived CBD in a transdermal cream provided significant symptom and pain relief for the patients described in this case series. Based on these results, we believe further investigation is warranted to see if CBD-containing products should have a more prominent role in the treatment of acute and chronic pain.

The combination of promethazine and opioids is known to have an opioid-sparing effect, thereby facilitating a reduction in total patient opioid consumption. In recent years, this practice has fallen out of favor in many healthcare facilities, except primarily in the post anesthesia care unit (PACU). The goal of this study was to highlight the potential of promethazine as a direct or indirect adjuvant medication in acute pain management. The present investigation was undertaken with a case series of adult female patients who underwent open total abdominal hysterectomies. Data from the PACU was reviewed with patients being separated into two groups. Group 1 received only intravenous opioids for acute pain management. Group 2 received a combination of intravenous opioids for acute pain management and intravenous promethazine for nausea and/or vomiting. Patients were discharged from the PACU with a modified Aldrete score of 9 or 10. The study showed that patients who received promethazine in addition to opioids were discharged from the PACU an average of 19.2 minutes earlier than those patients who received only opioids (p=0.003). The time to achieve modified Aldrete score of 9 or higher was more quickly achieved when open abdominal hysterectomy patients received promethazine in addition to opioids in the PACU. The study concluded that promethazine, in combination with opioids, could potentially decrease PACU stay postoperatively. Based on the present investigation, the prospect of using promethazine in other facets of pain management are intriguing and warrant future studies. Specifically, it may be worth investigating whether promethazine is truly an adjunct in combination with opioids and to determine if there are any other antihistamines or neuroleptics which may have similar clinical effects to promethazine.

Opiates are routinely used for chronic pain patients, and up to 44% of them will have a prescription for an opiate medication for pain alleviation. However, of the 76 million adults prescribed opiates for pain management, about 12% report misuse, and a large number of these may find themselves addicted to opioid medications. Opioid addiction is an ongoing epidemic, costing many lives. Withdrawal is very difficult. This requires providers to consider alternative analgesic plans and minimize opiate use. Here we report the use of a dexamethasone-dexmedetomidine combination for a regional nerve block in an elderly woman chronically treated with opiate medications who had previously failed opiate weaning. Following her nerve block, she was able to completely wean off of opioids and continues having good pain control with an opioid-free regimen.

Study Objective We report the first teenage case of ketamine-induced transient central diabetes insipidus. Case Summary The patient was an 18-year-old woman with moyamoya disease undergoing an external carotid to internal carotid bypass and given a low-dose ketamine infusion. After approximately 2 hours in the supine position, with 0.5 Minimum Alveolar Concentration (MAC) of sevoflurane, a propofol infusion at 50 μg/kg/min, a remifentanil infusion at 0.5 μg/kg/min, and a ketamine infusion at a dose of 10 μg/kg/min, this patient had an excessive urine output. Initially, the Foley catheter contained 50 mL of urine. She was given 1500 mL of crystalloid during the case but produced 2700 mL of urine output. Increasing urine output was noted 1 hour into the procedure around the time that the patient experienced a 2-minute Cushing-like response characterized by bradycardia and hypertension. Several I-Stat samples revealed a worsening hypernatremia. The decision was made to check the urine osmolality and treat the patient with 4 μg of desmopressin (DDAVP). Urine output began to slow down to a normal rate of 2 mg/kg/h, as the patient was transferred from the operating room to the computed tomographic (CT) scanning room for a CT and CT angiogram; both were unremarkable. The neurosurgery team waited until the next day to complete the procedure. The procedure was completed successfully and uneventfully the next day without a ketamine infusion as part of the general anesthetic plan. Discussion The Naranjo Adverse Drug Reaction score of 4 suggested a possible relationship between the patient's ketamine infusion and subsequent central diabetes insipidus. The 2 previous cases on this topic have suggested that ketamine, as an N -methyl-d-aspartate receptor antagonist, inhibits vasopressin release in the neurohypophysis. Conclusion Urine output, urine osmolarity, and serum osmolarity should be monitored in patients given ketamine anesthetic; desmopressin should be present to prevent dangerous long-term sequela.

This is a case report of a 48-year-old man with multiple transient ischemic attacks and a known hypoplastic right vertebral artery (VA) who presented after a syncopal event while turning his head to the left. The objective of this study is to demonstrate the necessity of proper diagnosis and management of cerebrovascular pathology including imaging and surgical intervention in patients with known anatomical anomalies. This study was conducted at Massachusetts, United States of America. Our patient's history was significant for a hypoplastic right VA and a stenotic segment of the right VA at the C3–C4 junction. There was also degeneration of the C3–C4 facet on the left, with osteophyte formation compressing the VA, and a fusion of the C2–C3 segment. Imaging demonstrated obliteration of the left VA flow with head rotation to the left and subsequent reconstitution of flow in the neutral position. After consultation, the patient decided to proceed with surgical management with an anterior cervical discectomy and fusion at the level of C3–C4. Symptoms of vertebrobasilar insufficiency including syncopal episodes resolved after treatment. VA anomalies, although uncommon, are important to understand. Our patient presented with an anomalous right VA, as well as severe degenerative changes to the C2/C3 vertebrae that contributed to the development of Bow Hunter's syndrome. It is essential that proper monitoring and follow-up has to be carried out in patients with abnormal cerebral vasculature to minimize the occurrence of Bow Hunter's syndrome.

Brown-Séquard syndrome, while uncommon, is a neurological condition that classically results from the hemisection of the spinal cord as a result of a penetrating injury to the spinal cord. We present a reported case of blunt trauma causing a high-energy cervical burst fracture/dislocation with a significant cord signal change producing Brown-Séquard syndrome. In this case, the burst fracture at the level of C5 obtained from the motor vehicle accident led to the damage of the left-sided lateral spinal thalamic tract, descending lateral cortical spinal tracts, and ascending dorsal column. This is a unique case of blunt nonpenetrating trauma leading to a high-energy cervical burst fracture/dislocation causing significant cord signal change on T2-weighted magnetic resonance imaging (MRI). These physical changes produced symptoms of neurologic impairment commonly seen in those patients with Brown-Séquard syndrome.

The purpose of this study is to evaluate the effectiveness of a multimodal approach to treating chronic low back pain. Chronic non-cancer-related back pain is often a frustrating and poorly managed problem for patients. It poses a significant public health issue worsened by the widespread use of narcotics. In 2016, the CDC released guidelines with noticeably more strict recommendations on prescription of narcotics for pain. Veterans at an interventional pain clinic presenting with chronic back pain refractory to medical and to surgical care were enrolled in an 8-week interdisciplinary pain management program. Pain scores were significantly reduced 1 year after completion of the program. Patients in this study benefitted from lower and sustained pain scores, a reduction in emergency room, and urgent care clinic visits, as well as generally high satisfaction with the interdisciplinary program.

Case series Patients: Male, 75-year old • Male, 23-year old • Male, 24-year old Final Diagnosis: COVID-19 pneumonia Symptoms: Fever • hypoxia • respiratory failure Medication: — Clinical Procedure: — Specialty: Anesthesiology • Critical Care Medicine • Infectious Diseases Objective: Unusual or unexpected effect of treatment Background: Icosapent ethyl, a form of eicosapentaenoic acid with anti-inflammatory activity, has been approved as an adjunctive treatment with statins in patients with hypertriglyceridemia. Icosapent ethyl is currently undergoing clinical trials to determine its anti-inflammatory effects in patients with coronavirus disease 2019 (COVID-19). This report describes 3 intensive care unit (ICU) patients with moderate to severe COVID-19 pneumonia treated with icosapent ethyl as part of their supportive care who had favorable outcomes. Case Reports: Case 1 was a 75-year-old man with a past medical history of hyperlipidemia, hypertension, type 2 diabetes mellitus, obesity, and benign prostatic hyperplasia. Case 2 was a 23-year old man with a past medical history of type 2 diabetes mellitus and obesity. Case 3 was a 24-year old man with a history of autism. All cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were confirmed from a nasopharyngeal swab using the Becton Dickinson nasopharyngeal reverse-transcription polymerase chain reaction. All patients in these cases were treated with a course of 2 g of icosapent ethyl twice a day by nasogastric tube. Conclusions: This report of 3 cases describes the use of icosapent ethyl as a component of supportive treatments in ICU patients with moderate to severe COVID-19 pneumonia. However, as of yet there are no evidence-based treatments for SARS-CoV-2 infection from controlled clinical trials. The outcomes of ongoing clinical trials are awaited to determine whether icosapent ethyl has anti-inflammatory effects in patients with SARS-CoV-2 infection and which patients might benefit from the use of this adjunctive treatment.

Preemptive analgesia is focused on both the prevention and treatment of postoperative pain. There are several factors at play related to postoperative pain and the individual patient. Furthermore, sensitization is an important aspect to consider when determining an appropriate analgesic plan for patients. Similarly, exposure to noxious stimuli for prolonged periods or of high frequency in the periphery can lead to changes in the central nervous system pain processing centers, which can affect the appropriate analgesic plan for patients. Pain can be controlled in several phases of perioperative care including pre-, peri-, and postoperative periods, and many agents can be used as preemptive analgesic treatments such as NSAIDs, local anesthetics, opioids, and NMDA receptor antagonists. Local wound infiltration is being used in conjunction with nerve blocks and is becoming an efficient method of postoperative pain control. Regional anesthesia is also continuing to grow and is used for a wide variety of procedures in the treatment of chronic pain. Several complex pain syndromes are discussed in this chapter, as well as the diagnostic criteria and how to treat them. Overall, the value of comprehensive pain control for surgical patients should not be underestimated and is likely to be best addressed with a multimodal, patient-specific approach.

Background: Pain emanating from the sacroiliac (SI) joint can have variable radiation patterns. Single physical examination tests for SI joint pain are inconsistent with multiple tests increasing both sensitivity and specificity. Objective: To evaluate the use of fluoroscopy in the diagnosis of SI joint pain. Study Design: Prospective double blind comparison study Setting: Pain clinic and radiology setting in urban Veterans Administration (VA) in New Orleans, Louisiana. Methods: Twenty-two adult men, patients at a southeastern United States VA interventional pain clinic, presented with unilateral low back pain of more than 2 months’ duration. Patients with previous back surgery were excluded from the study. Each patient was given a Gapping test, Patrick (FABERE) test, and Gaenslen test. A second blinded physician placed each patient prone under fluoroscopic guidance, asking each patient to point to the most painful area. Pain was provoked by applying pressure with the heel of the palm in that area to determine the point of maximum tenderness. The area was marked with a radio-opaque object and was placed on the mark with a fluoroscopic imgage. A site within 1 cm of the SI joint was considered as a positive test. This was followed by a diagnostic injection under fluoroscopy with 1 mL 2% lidocaine. A positive result was considered as more than 2 hours of greater than 75% reduction in pain. Then, in 2-3 days this was followed by a therapeutic injection under fluoroscopy with 1 mL 0.5% bupivacaine and 40 mg methylprednisolone. Results: Each patient was reassessed after 6 weeks. The sensitivity and specificity in addition to the positive and negative predictive values were determined for both the conventional examinations, as well as the examination under fluoroscopy. Finally, a receiver operating characteristic (ROC) curve was constructed to evaluate test performance. The sensitivity and specificity of the fluoroscopic examination were 0.82 and 0.80 respectively; Positive predictive value and negative predictive value were 0.93 and 0.57 respectively. The area under ROC curve was 0.812 which is considered a “good” test; however the area under ROC for the conventional examination were between 0.52 -0.58 which is considered “poor to fail”. Limitations: Variation in anatomy of the SI joint, small sample size. Conclusions: Multiple structures of the SI joint complex can result in clinical symptoms of pain. These include intra-articular structures (degenerative arthritis, and inflammatory conditions) as well as extraarticular structures (ligaments, muscles, etc.). Key words: Sacroilliac joint disease, radicular pain, thigh thrust test, compression test, distraction test, Gaenslen test, Patrick test (FABER test)

Study design We evaluated 43 patients diagnosed with tandem spinal stenosis (TSS) from 1999 to 2005 in an academic hospital. Objective The purpose of this study is to compare outcomes after simultaneous decompression of the cervical and lumbar spine versus staged operations. Summary of background data TSS is a rare degenerative disease affecting multiple spinal levels with limited research describing operative management. Methods Of our patients, 21 underwent simultaneous decompression of both the cervical and lumbar spine and 22 underwent staged decompression of the cervical spine followed by the lumbar spine at a later date. Medical records were reviewed for patient demographics, type and duration of symptoms, operative time, combined blood loss, cervical myelopathy modified Japan Orthopaedic Association Score, Oswestry Disability Index (ODI), major and minor complications, and average length of follow up. Each category was evaluated by Pearson correlations and unpaired Student t tests. Results With a mean follow-up of 7 years, both groups improved in JOA and ODI without a significant difference between the 2 operative groups in terms of major or minor complications, JOA, or ODI. Independent of the surgical algorithm, age above 68 years, estimated blood loss ≥400 mL, and operative time ≥150 minutes significantly increased the number of complications. Conclusions These results indicate that TSS can be effectively managed by either surgical intervention, simultaneous, or staged decompressions. However, patient age, blood loss, and operative time do significantly impact outcomes. Therefore, operative management should be tailored to the patient's age and the option which will limit blood loss and operative time, whether that is by simultaneous or staged procedures.

STUDY DESIGN This is a case report of a posterior extrusion of the polyethylene core from a CHARITE arthroplasty. This is the first reported case of posterior dislocation of the polyethylene and the revision strategies used to correct this problem. OBJECTIVE To report a novel failure mechanism and revision strategy for CHARITE total disc arthroplasty (TDA). SUMMARY OF BACKGROUND DATA Case report at a Level 1 tertiary care referral center in the northeastern United States. METHODS This is a case report and review of the literature of a patient who sustained posterior dislocation of the polyethylene core from a CHARITE TDA several months after the index procedure. RESULTS Core dislocation is a known complication of TDA. However, of the known reported dislocations all have been anterior. This case describes the first known occurrence of posterior core dislocation and the revision strategy for this problem. CONCLUSION This case report highlights the first known case of a posterior dislocation of a CHARITE core. It is likely that altered biomechanical forces generated over time attributed to device failure. An instrumented posterior fusion with removal of the core is what ultimately led to a stable revision construct.

BACKGROUND: Traditional techniques for the treatment of isthmic spondylolisthesis pass a fibular dowel graft across the L5-S1 disc by using the anterior portion of the L5 body. OBJECTIVE: To introduce a technique for the treatment of isthmic spondylolisthesis in the setting of multilevel degenerative disc disease in adults. Our modified technique allows us to traverse the L5-S1 disc via the L4-5 disc space thereby treating the degenerated disc at L4-5 simultaneously. METHODS: A standard anterior discectomy was performed on L4-5. Using biplanar fluoroscopy, a Kirschner wire was placed beginning at the anterior third of the L5 superior endplate and ending at S1. An anterior cruciate ligament reamer was used to make a channel for the fibular allograft. Then, a femoral ring allograft was placed in the disc space at L4-5, and standard anterior lumbar interbody fusions were performed at any additional cephalad level(s). Afterward, posterior instrumented fusion was performed to complement the anterior fusion procedure (except at L5), and wide decompression followed. RESULTS: All patients presented with isthmic spondylolisthesis and all had multilevel fusions. The mean slip angle was 32.6 degrees (37.8 degrees preoperatively), and mean lumbar index was 67%. After the procedure, the average endplate-to-dowel angle was 107.1 degrees compared with 134 degrees. All patients had clinical and radiographic evidence of solid fusion without the need for revisions. CONCLUSION :The proposed advantage of our modified technique is twofold. The graft is placed nearly perpendicular to the L5-S1 interface, as it will behave more efficiently with respect to interfragmental compression. Also, surgeons gain access to fuse L4-5 anteriorly and posteriorly.

A 70-year-old woman with a history of bilateral primary knee osteoarthritis presented with a left knee wound complication, a non-Hodgkins lymphoma, after bilateral total knee arthroplasties. After exploring several etiologies, the evidence in this unusual case suggests a coincidental preexisting lymphoma.

Children with pelvic osteomyelitis may present with symptoms that are nonspecific. Conventional imaging modalities including plain radiographs, ultrasound, technetium bone scan, and computed tomography rarely demonstrate pathology that is diagnostic of this condition. As a result, accurate diagnosis is often delayed, and children may undergo surgical diagnostic or therapeutic procedures that may be avoided. We report the radiographic and magnetic resonance imaging (MRI) findings in 23 children admitted with a suspected diagnosis of pelvic osteomyelitis. We are presenting imaging findings in children with suspected pelvic osteomyelitis with emphasis on MRI abnormalities and to propose an anatomical classification based on the patterns of pelvic involvement.The medical records and imaging reports of all patients admitted to our institution with a history and physical examination suggestive of pelvic osteomyelitis between July 31, 1992, and March 10, 2003 were reviewed. Criteria were defined for the diagnosis of pelvic osteomyelitis based on criteria used by Farley et al in 1985. Specific attention was paid to the imaging strategies used and the influence of each radiographic method on the ultimate diagnosis.Abnormalities on the MRI included soft tissue inflammation and bone edema. These findings were bright on T2 and short inversion time Short T1 inversion recovery (STIR) images and enhanced after gadolinium administration. Five distinct patterns of pelvic involvement were observed, each corresponding to a cartilaginous epiphysis or apophysis. These were the sacroiliac joint, triradiate cartilage, pubic symphysis, ischium, and iliac apophysis. One patient had a noninfectious cause of presentation with a deep vein thrombosis, whereas another was diagnosed with Hodgkin lymphoma in addition to osteomyelitis of the ischium.Magnetic resonance imaging is a sensitive technique for evaluation of pyogenic infections involving the pelvis. In patients presenting with clinical findings and laboratory studies suggesting an infectious process, MRI with gadolinium enhancement should be performed as an early study. Magnetic resonance imaging is also effective in identifying other conditions that may resemble pelvic osteomyelitis.

We report a case of paradoxical presentation of a postural postdural puncture headache secondary to dural puncture with a 25-gauge Whitacre needle for combined spinal-epidural anesthesia. This 27-year-old female patient presented to the emergency department with elevated blood pressure and a global headache 9 days after administration of epidural anesthesia for a spontaneous vaginal delivery after an uncomplicated pregnancy. The patient reported that the headache was more intense when lying down and immediately improved when she sat or stood up from a recumbent position. The patient was discharged from emergency department after an improvement following treatment with labetalol, ondansetron, ketorolac, and fluid resuscitation.

Background: C5 nerve palsy is a known complication of cervical spine surgery. The development and etiology of this complication are not completely understood. The purpose of the present study was to determine whether rotation of the cervical spinal cord predicts the development of a C5 palsy. Methods: We performed a retrospective review of prospectively collected spine registry data as well as magnetic resonance images. We reviewed the records for 176 patients with degenerative disorders of the cervical spine who underwent anterior cervical decompression or corpectomy within the C4 to C6 levels. Our measurements included area for the spinal cord, space available for the cord, and rotation of the cord with respect to the vertebral body. Results: There was a 6.8% prevalence of postoperative C5 nerve palsy as defined by deltoid motor strength of ≤3 of 5. The average rotation of the spinal cord (and standard deviation) was 2.8° ± 3.0°. A significant association was detected between the degree of rotation (0° to 5° versus 6° to 10° versus ≥11°) and palsy (point-biserial correlation = 0.94; p < 0.001). A diagnostic criterion of 6° of rotation could identify patients who had a C5 palsy (sensitivity = 1.00 [95% confidence interval, 0.70 to 1.00], specificity = 0.97 [95% confidence interval, 0.93 to 0.99], positive predictive value = 0.71 [95% confidence interval, 0.44 to 0.89], negative predictive value = 1.00 [95% confidence interval, 0.97 to 1.00]). Conclusions: Our evidence suggests that spinal cord rotation is a strong and significant predictor of C5 palsy postoperatively. Patients can be classified into three types, with Type 1 representing mild rotation (0° to 5°), Type 2 representing moderate rotation (6° to 10°), and Type 3 representing severe rotation (≥11°). The rate of C5 palsy was zero of 159 in the Type-1 group, eight of thirteen in the Type-2 group, and four of four in the Type-3 group. This information may be valuable for surgeons and patients considering anterior surgery in the C4 to C6 levels. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN: This is a prospective study. OBJECTIVE: The aim of our study is to identify whether vertebral arteries (VA), normal or aberrant, are routinely described in cervical spine magnetic resonance imaging (MRI) interpretations. SUMMARY OF BACKGROUND DATA: VA injury is a serious complication of anterior cervical spine surgery. Aberrant VA anatomy is a potential cause of such complications. Therefore, VA anatomy should be evaluated in cervical MRIs. METHODS: Six neuroradiologists were blinded to the study design and were asked to interpret 79 cervical MRIs. Of these, 39 had aberrant VAs, whereas 40 had normal VAs. Initially, the indications for the study included only a description of patient's symptoms. The radiologists were then given the same MRIs with different indications. This time, the indications included the patient's symptoms, a request for annotations on the VA, and a definition of VA anomaly. All of the MRI interpretations were then evaluated for the frequency and accuracy of VA description. RESULTS: When the indications for the study did not specifically request a comment on VAs, the VA was never described (0%). When the indications included the specific request and definition, all 6 commented on the VA (100%). Three of the 6 radiologists were 100% accurate in identifying all 40 normal and 39 aberrant VAs, whereas the other 3 identified all 40 normal and 38 of 39 aberrant VAs. CONCLUSION: This study demonstrates that the VA is not a standard component of cervical spine MRI interpretations. Because of the significant complications related to its injury, VA anatomy, whether normal or variant, needs to be evaluated in cervical MRIs. When ordering a cervical MRI, surgeons should request a description of the VA and any anomalies.

A case report of a 58-year-old man who sustained a laceration of his left vertebral artery during a routine corpectomy for cervical myelopathy is reported. To report iatrogenic injury of a tortuous vertebral artery during anterior cervical spine surgery and discuss appropriate diagnosis and treatment options for this complication. UMass Memorial Medical Center, Worcester, MA, USA. Vertebral artery anomalies, although rare, are typically present with degenerative processes and great care must be taken to avoid damage during a corpectomy. Cross-sectional imaging coupled with intraoperative angiography is helpful for the urgent evaluation of the injury site and identification of the contralateral vertebral artery's status. This is a single case of a patient sustaining a laceration of the left vertebral artery during surgery, which resulted in a lateral medullary stroke. After the left vertebral artery laceration, hemostasis was achieved. With the intent to better visualize and possibly embolize or stent the injury, an angiographic study was carried out. The angiogram revealed a laceration of the left vertebral artery within the vertebral foramina at vertebral body level C6, but intact distal flow. The patient underwent angiographic embolization and a subsequent magnetic resonance imaging (MRI) revealed a left lateral medullary stroke consistent with the lack of flow through the left vertebral artery from C6 to the basilar artery. If a tortuous vertebral artery is suspected, then meticulous review of preoperative cross-sectional imaging should be implemented along with angiographic examination. If anomalies are detected and the standard procedure cannot be safely carried out, then alterations, such as preoperative stent placement, need to be considered.