Posterior pedicle screw fixation combined with local steroid injections for treating axial eosinophilic granulomas and atlantoaxial dislocation:A case report

BACKGROUND Eosinophilic granuloma(EG)is a proliferative condition that affects the cells of bone tissue.There are no specific clinical signs or imaging manifestations in the early stages of the disease,making it simple to overlook and misdiagnose.Because of the disease's rarity,there is presently no standardized treatment principle.There are few accounts of such occurrences affecting the axis among children.We discovered a case of a child whose EG resulted in atlantoaxial joint dislocation and destruction of the axial bone.CASE SUMMARY After having pharyngeal discomfort for more than six months without a clear explanation,a 6-year-old boy was brought to our hospital.Following a careful evaluation,the pathology indicated a strong likelihood of an axial EG.Ultimately,we decided to treat the boy with posterior pedicle screw fixation and local steroid injections.CONCLUSION EGs of the upper cervical spine are quite uncommon in children,and they are exceedingly easy to overlook or misdiagnose.Posterior pedicle screw fixation and local steroid injections are effective treatments for patients with axial EGs affecting the atlantoaxial junction.

Ultrasound, Fluoroscopic-Guided Caudal, Lumbar Epidural Steroid Injections and Blinding Paraspinal Lumbosacral Steroid Injections in Patients with Low Back Pain with Radiculopathy

Background and Aims: Low back pain (LBP) is considered one of the most common health conditions in the world right now, and it affects many individuals throughout different stages of their lives. Chronic LBP (CLBP) was estimated to be between 5% and 10%, defined as LBP that lasts for 12 weeks. The most common causes of CLBP with radiculopathy are lumbar disc prolapse (LDP) and degenerative facet osteoarthropathy (DFO);the aim of this study is to investigate the efficacy of ultrasound (US) guided, fluoroscopy (FL) guided, Caudal Epidural Steroid Injection (CESI), lumbar epidural steroid injections (LESI), and blinding lumbosacral steroid injections (LSPSI) in patients with CLBP with radiculopathy. Patients and Methods: This is a randomized prospective study that was conducted at the department of rheumatology at Al Azhar University Hospital in Egypt between November 2020 and August 2021. A total of 100 patients with refractory CLBP with radiculopathy were enrolled in the study. Consequently, they were divided into 2 groups: the first consisted of fifty patients with CLBP and radiculopathy caused by LDP, as determined by lumbosacral magnetic resonance imaging (MRI), and the second group consisted of fifty patients with refractory low back pain and radiculopathy caused by DFO, as determined by lumbosacral plain x-rays and lumbosacral MRI. The following procedures were performed: US-guided CESI, FL-guided CESI, FL-guided LESI, US-guided LESI, and blinding LSPSI. Results: In the LDP group, there is a statistically significant difference between considered spinal nerve roots as regards Visual Analogue Scale (VAS) (at 2 months). Likewise, a statistically significant difference was found between blinding LSPSI and US-Guided LESI with respect to VAS (baseline) and VAS (2 months) (P-value = 0.018 and 0.003, respectively). Statistically significant differences were reported in VAS (2 months) for both FL-guided LESI and FL-guided CESI groups. Considering the VAS of studied spinal nerve roots in the DFO group, there is a statistically significant difference between the examined spinal nerve roots with respect to Oswestry Disability Index (ODI) (2 months). Similarly, there is a statistically significant difference in VAS (2 months) between US-guided LESI and para-spinal roots and FL-guided LESI and para-spinal roots (P-value = 0.038 and 0.021, respectively). Additionally, there is a statistically significant difference between the US-guided CESI, FL-guided CESI, FL-guided LESI, and spinal nerve roots with respect to ODI (at 2 months). (P-value = 0.033, 0.025 and 0.005, respectively). Conclusion: US is excellent in guiding CESI and LESI and should be the preferred alternative when FL is not provided, with a similar treatment outcome compared to FL-CESI and LESI.

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

Background:The prevalence of low back pain with radiculopathy in general population varies from 9.9%to 25%,which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc.Transforaminal epidural injection of a mixture of long-acting anaesthetic(bupivacaine)and particulate steroids(depomedrol)has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications.Methods:To analyze the effectiveness of transforaminal epidural steroid injection(TFESI)in the treatment of low back pain with radiculopathy,a retrospective case series evaluating the records of patients that received TFESI(1 mL 0.5%bupivacaine+1 ml/40 mg depomedrol)under C-arm guidance from January 2015 to December 2018(3 years)at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences(UDM-NINAS),their lumbosacral MRI and the pre-procedure,1-week and 3-month numeric pain rating scale,were analyzed.Successful treatment(reduction of pain scale by more than 50%of baseline at 3 months)in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared.Results:Out of 67 patients that received TFESI,35(52.23%)could be followed up.The mean age was 55.8±14.39 years and 51.3%were females.68.57%had L5 and 20%had S1 radiculopathy.Bony recess stenosis was seen in the aged 40%and PIVD was the cause of radiculopathy in 60%.The median duration of radicular pain prior to intervention was 3 months.TFESI was effective as the mean numeric pain scale before injection was 8.97±1.32 which reduced to 3.91±3.23(paired t test p value<0.001)at 1 week post injection and 3.23±3.34(paired t test p value<0.001)at 3 months post injection.Twenty-six of the 35 patients(75.29%)had more than 50%pain relief compared to baseline at 3 months and were satisfied.Nine patients continued to have pain;however,only one required a surgical intervention.The effectiveness of TFESI was not significantly different in different ages(Fisher’s exact test p value 0.182)and in different anatomic levels(Fisher’s exact test p value 0.241).Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD,though it was not statistically significant(Fischer’s exact test p value 0.688).There were no adverse events recorded.Conclusion:TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.