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Background Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity. Case report We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age. Discussion With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called “Pelvic pain syndrome” and transient osteoporosis of the hip. Conclusion Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications., Highlights • Corticosteroids and alcohol intake are the most common atraumatic cause of hip osteonecrosis • Hip and pelvic pain during pregnancy are very frequent and may hide a serious event such as hip avascular necrosis • Hip avascular necrosis can have disastrous complications if not diagnosed in young pregnant women. • Having a high index of suspicion in a pregnant woman with hip pain is a must to prevent such complications

Schwannomas are benign tumors affecting the nerve sheath. Their presence in the subperiosteal region is extremely rare. We report a case of a 66-year-old male patient with a 10-year history of unexplained pain of the anterior leg that turned out to be caused by a subperiosteal schwannoma of the mid-tibia. We believe this case report will increase surgeons' index of suspicion about this condition when dealing with cases of unexplained bony pain, consequently allowing for early diagnosis and better outcomes.

We present a case of a 38-year-old female patient, presenting with debilitating simultaneous bilateral avascular necrosis of the femoral head (AVNFH) 10 years after cocaine detoxification, making her wheelchair-bound for six months. This case is reported for the rarity of association of cocaine with AVNFH, and for the unique fact of the simultaneous bilateral condition occurring a long time after cocaine ingestion in the absence of other important risk factors. This report postulates cocaine as a possible cause of bilateral AVNFH, which can increase the index of suspicion of this pathology, allowing early diagnosis and better outcomes.

Study design Retrospective matched cohort study. Objective To determine if low-pressure lumbar provocation discography (PD) results in long-term accelerated disc degeneration, internal disc disruption, or disc herniation in patients with symptomatic low back pain (LBP). Summary of background data Study of subjects without clinically-significant LBP suggests that high-pressure PD may accelerate disc degeneration. Methods Consecutive patients with symptomatic LBP who underwent magnetic resonance imaging (MRI), PD, and repeat MRI more than 7 years later, but did not undergo subsequent spinal fusion surgery, were included. Punctured discs were matched (1:2 to 1:4) to corresponding discs in a control cohort by age, BMI, Pfirrmann score (±2), and presence of disc herniation; control cohort inclusion required MRIs for symptomatic LBP, separated by more than 7 years. The primary outcome of the study was a progression in Pfirrmann score category (I-II, III-IV, V). MRI disc-to-CSF T2 signal-intensity ratio, disc height, disc herniations, high intensity zones (HIZs), and Modic changes were assessed. Results Baseline and follow-up MRIs were available for 77 discs exposed to PD, and for 260 discs in the matched control cohort. There was no difference in the proportion of punctured discs that advanced in Pfirrmann score category in the PD group (17%, 95% CI 9-27%) compared with corresponding discs in the Control group (21%, 95% CI 17-27%), P = 0.3578, or in non-punctured discs in the PD group (35%, 95% CI 21-51%) compared with corresponding discs in the Control group (34%, 95% CI 27-42%), P = 0.1169. There were no differences in disc-to-CSF T2 signal-intensity ratio, presence of disc herniations, HIZs, or Modic changes following puncture in the PD versus matched cohort discs or in the non-punctured PD cohort discs versus corresponding control cohort discs (P > 0.05). Conclusion Patients with symptomatic LBP who underwent low-pressure PD, but who did not undergo a subsequent spinal fusion surgery, developed disc degeneration and new disc herniations at a similar rate to corresponding discs in matched control patients. Level of evidence 3.

Minimally invasive posterior spinous process–splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process–splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36–87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process–splitting laminoplasty was 2.2 (range, 1–6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain ( P P P =.0017) for the physical component and 21.8±25.6 points ( P =.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process–splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [ Orthopedics. 2016; 39(5):e950–e956.]

We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques in patients with a diagnosis of either ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). A retrospective review of patients known to have AS or DISH treated for spinal column fracture at a single institution between 1995 and 2011 was performed. Patients were analyzed by the type of fixation, divided into either a percutaneous group (PG) or an open group (OG). There were 41 patients identified with a spinal column fracture and history of AS or DISH who received surgical intervention. There were 17 (42%) patients with AS and 24 (58%) with DISH. Patients in the PG and OG cohorts presented with similar mechanisms of injury, Injury Severity Scale, number of vertebral fractures, number of additional injuries, and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification scores. Mean operative time (254.76minutes versus 334.67minutes, p=0.040), estimated blood loss (166.8 versus 1240.36mL, p

The surgical management of metastatic disease of the spine continues to evolve. For most of the recent three decades, radiation therapy provided the mainstay of treatment for patients with symptomatic metastatic disease of the spine. Surgical treatment during this era often involved dorsal spinal cord decompression with no or limited spinal instrumentation1,2. These procedures generally provided only an indirect decompression of the spinal cord and often increased spinal instability. However, with advances in the understanding of metastatic processes in the spine and evolution of surgical techniques and instrumentation, surgical treatment plays a prominent role in the care of patients with metastatic epidural spinal cord compression. Studies have now yielded Level-I evidence on the efficacy of surgery for metastatic disease of the spine for improving quality of life and outcomes in patients with spinal metastasis. Concurrently, advances in radiation oncology now allow high-precision targeting of tumors and increased efficacy when treating radioresistant lesions3. These advances together have led to important advances in the treatment of metastatic disease of the spine. Research findings continue to identify appropriate candidates for surgical intervention for metastatic spinal disease as well as to define optimal surgical and radiation therapy techniques. In considering treatment methods, it is essential to account for factors such as tumor type and/or biology, extent of disease, neurologic status, an individual patient’s expectations, quality of life, and life expectancy. For example, hematopoietic tumors reliably respond to radiation therapy and rarely require surgery for a compressive neurologic deficit alone. Aggressive surgical intervention may be futile in the face of established neurologic deficit and/or rapidly advancing tumor refractory to treatments. However, many patients continue to present with symptomatic solid organ metastases and reasonable life expectancies and will benefit from a comprehensive evaluation by surgeons in concert with medical and …

Extensor tendon rupture is a common condition following penetrating injuries, whereas closed rupture is rare unless in a mallet finger. We describe an unusual case of closed rupture of both extensor tendons to the index finger. The extensor indicis proprius and extensor digitorum longus were avulsed proximal to the extensor retinaculum in a 23-year-old male patient due to forced hyperflexion of his index finger.

Aneurysmal bone cysts rarely affect the carpus. We present a case of aneurysmal bone cyst affecting the lunate. Curettage and bone grafting of the lesion was successful, with no recurrence after 2 years of follow-up.

We present a case of delayed presentation of a subdural haematoma causing cauda equina syndrome which occurred 96 hours after a spinal anaesthetic had been administered for an elective total hip replacement in an 86-year-old man. The patient had received low-molecular-weight heparin anticoagulation which had been delayed until 12 hours postoperatively. No other cause of the haemorrhage could be identified.